401k Plan data: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA plan

THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 401k Plan overview

Plan Name	THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA
Plan identification number	501

THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA Benefits

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

401k Sponsoring company profile

THE UNIVERSITY OF VERMONT MEDICAL CENTER has sponsored the creation of one or more 401k plans.

Company Name: THE UNIVERSITY OF VERMONT MEDICAL CENTER

Employer identification number (EIN): 030219309

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-01-01 SARA PRYCE 2022-10-17
501 2021-01-01 SARA PRYCE 2023-07-06
501 2020-01-01 KRISTEN CARRIS 2021-09-16
501 2019-01-01 KRISTEN CARRIS 2020-08-07
501 2018-01-01 KRISTEN CARRIS 2019-07-30
501 2017-01-01
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01 JOHN M HERKO JOHN M HERKO 2014-07-22
501 2012-01-01 JOHN M HERKO JOHN M HERKO 2013-10-14
501 2011-01-01 JOHN M HERKO JOHN M HERKO 2012-07-24
501 2010-01-01 JOHN M HERKO JOHN M HERKO 2011-08-17
501 2009-01-01 JOHN M HERKO JOHN M HERKO 2010-07-29

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-01-01	SARA PRYCE	2022-10-17
501	2021-01-01	SARA PRYCE	2023-07-06
501	2020-01-01	KRISTEN CARRIS	2021-09-16
501	2019-01-01	KRISTEN CARRIS	2020-08-07
501	2018-01-01	KRISTEN CARRIS	2019-07-30
501	2017-01-01
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01	JOHN M HERKO		JOHN M HERKO	2014-07-22
501	2012-01-01	JOHN M HERKO		JOHN M HERKO	2013-10-14
501	2011-01-01	JOHN M HERKO		JOHN M HERKO	2012-07-24
501	2010-01-01	JOHN M HERKO		JOHN M HERKO	2011-08-17
501	2009-01-01	JOHN M HERKO		JOHN M HERKO	2010-07-29

Plan Statistics for THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA

401k plan membership statisitcs for THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA

Measure Date Value
2021: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2021 401k membership
Total participants, beginning-of-year 2021-01-01 8,436
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 7,789
Number of retired or separated participants receiving benefits 2021-01-01 600
Number of other retired or separated participants entitled to future benefits 2021-01-01 83
Total of all active and inactive participants 2021-01-01 8,472
2020: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2020 401k membership
Total participants, beginning-of-year 2020-01-01 8,436
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 7,792
Number of retired or separated participants receiving benefits 2020-01-01 577
Number of other retired or separated participants entitled to future benefits 2020-01-01 67
Total of all active and inactive participants 2020-01-01 8,436
2019: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2019 401k membership
Total participants, beginning-of-year 2019-01-01 7,885
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 7,695
Number of retired or separated participants receiving benefits 2019-01-01 574
Number of other retired or separated participants entitled to future benefits 2019-01-01 65
Total of all active and inactive participants 2019-01-01 8,334
2018: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2018 401k membership
Total participants, beginning-of-year 2018-01-01 7,739
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 7,306
Number of retired or separated participants receiving benefits 2018-01-01 519
Number of other retired or separated participants entitled to future benefits 2018-01-01 60
Total of all active and inactive participants 2018-01-01 7,885
2017: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2017 401k membership
Total participants, beginning-of-year 2017-01-01 7,743
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 6,999
Number of retired or separated participants receiving benefits 2017-01-01 553
Number of other retired or separated participants entitled to future benefits 2017-01-01 187
Total of all active and inactive participants 2017-01-01 7,739
2016: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2016 401k membership
Total participants, beginning-of-year 2016-01-01 7,403
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 7,017
Number of retired or separated participants receiving benefits 2016-01-01 505
Number of other retired or separated participants entitled to future benefits 2016-01-01 221
Total of all active and inactive participants 2016-01-01 7,743
2015: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2015 401k membership
Total participants, beginning-of-year 2015-01-01 7,122
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 6,863
Number of retired or separated participants receiving benefits 2015-01-01 484
Number of other retired or separated participants entitled to future benefits 2015-01-01 56
Total of all active and inactive participants 2015-01-01 7,403
2014: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2014 401k membership
Total participants, beginning-of-year 2014-01-01 6,887
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 6,598
Number of retired or separated participants receiving benefits 2014-01-01 477
Number of other retired or separated participants entitled to future benefits 2014-01-01 47
Total of all active and inactive participants 2014-01-01 7,122
2013: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2013 401k membership
Total participants, beginning-of-year 2013-01-01 6,786
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 6,436
Number of retired or separated participants receiving benefits 2013-01-01 416
Number of other retired or separated participants entitled to future benefits 2013-01-01 35
Total of all active and inactive participants 2013-01-01 6,887
2012: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2012 401k membership
Total participants, beginning-of-year 2012-01-01 6,527
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 6,340
Number of retired or separated participants receiving benefits 2012-01-01 411
Number of other retired or separated participants entitled to future benefits 2012-01-01 35
Total of all active and inactive participants 2012-01-01 6,786
2011: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2011 401k membership
Total participants, beginning-of-year 2011-01-01 6,203
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 6,096
Number of retired or separated participants receiving benefits 2011-01-01 398
Number of other retired or separated participants entitled to future benefits 2011-01-01 33
Total of all active and inactive participants 2011-01-01 6,527
2010: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2010 401k membership
Total participants, beginning-of-year 2010-01-01 6,169
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 5,791
Number of retired or separated participants receiving benefits 2010-01-01 383
Number of other retired or separated participants entitled to future benefits 2010-01-01 29
Total of all active and inactive participants 2010-01-01 6,203
2009: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2009 401k membership
Total participants, beginning-of-year 2009-01-01 5,009
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 5,805
Number of retired or separated participants receiving benefits 2009-01-01 364
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 6,169

Measure	Date	Value
2021: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2021 401k membership
Total participants, beginning-of-year	2021-01-01	8,436
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	7,789
Number of retired or separated participants receiving benefits	2021-01-01	600
Number of other retired or separated participants entitled to future benefits	2021-01-01	83
Total of all active and inactive participants	2021-01-01	8,472
2020: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2020 401k membership
Total participants, beginning-of-year	2020-01-01	8,436
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	7,792
Number of retired or separated participants receiving benefits	2020-01-01	577
Number of other retired or separated participants entitled to future benefits	2020-01-01	67
Total of all active and inactive participants	2020-01-01	8,436
2019: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2019 401k membership
Total participants, beginning-of-year	2019-01-01	7,885
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	7,695
Number of retired or separated participants receiving benefits	2019-01-01	574
Number of other retired or separated participants entitled to future benefits	2019-01-01	65
Total of all active and inactive participants	2019-01-01	8,334
2018: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2018 401k membership
Total participants, beginning-of-year	2018-01-01	7,739
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	7,306
Number of retired or separated participants receiving benefits	2018-01-01	519
Number of other retired or separated participants entitled to future benefits	2018-01-01	60
Total of all active and inactive participants	2018-01-01	7,885
2017: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2017 401k membership
Total participants, beginning-of-year	2017-01-01	7,743
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	6,999
Number of retired or separated participants receiving benefits	2017-01-01	553
Number of other retired or separated participants entitled to future benefits	2017-01-01	187
Total of all active and inactive participants	2017-01-01	7,739
2016: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2016 401k membership
Total participants, beginning-of-year	2016-01-01	7,403
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	7,017
Number of retired or separated participants receiving benefits	2016-01-01	505
Number of other retired or separated participants entitled to future benefits	2016-01-01	221
Total of all active and inactive participants	2016-01-01	7,743
2015: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2015 401k membership
Total participants, beginning-of-year	2015-01-01	7,122
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	6,863
Number of retired or separated participants receiving benefits	2015-01-01	484
Number of other retired or separated participants entitled to future benefits	2015-01-01	56
Total of all active and inactive participants	2015-01-01	7,403
2014: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2014 401k membership
Total participants, beginning-of-year	2014-01-01	6,887
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	6,598
Number of retired or separated participants receiving benefits	2014-01-01	477
Number of other retired or separated participants entitled to future benefits	2014-01-01	47
Total of all active and inactive participants	2014-01-01	7,122
2013: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2013 401k membership
Total participants, beginning-of-year	2013-01-01	6,786
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	6,436
Number of retired or separated participants receiving benefits	2013-01-01	416
Number of other retired or separated participants entitled to future benefits	2013-01-01	35
Total of all active and inactive participants	2013-01-01	6,887
2012: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2012 401k membership
Total participants, beginning-of-year	2012-01-01	6,527
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	6,340
Number of retired or separated participants receiving benefits	2012-01-01	411
Number of other retired or separated participants entitled to future benefits	2012-01-01	35
Total of all active and inactive participants	2012-01-01	6,786
2011: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2011 401k membership
Total participants, beginning-of-year	2011-01-01	6,203
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	6,096
Number of retired or separated participants receiving benefits	2011-01-01	398
Number of other retired or separated participants entitled to future benefits	2011-01-01	33
Total of all active and inactive participants	2011-01-01	6,527
2010: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2010 401k membership
Total participants, beginning-of-year	2010-01-01	6,169
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	5,791
Number of retired or separated participants receiving benefits	2010-01-01	383
Number of other retired or separated participants entitled to future benefits	2010-01-01	29
Total of all active and inactive participants	2010-01-01	6,203
2009: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2009 401k membership
Total participants, beginning-of-year	2009-01-01	5,009
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	5,805
Number of retired or separated participants receiving benefits	2009-01-01	364
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	6,169

Form 5500 Responses for THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA

2021: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	Yes
2021-01-01	This submission is the final filing	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	Yes
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: THE UNIVERSITY OF VERMONT MEDICAL CENTER EMPLOYEE WELFARE BENEFITS PLAN DCRA 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ADDS08828

Policy instance

Insurance contract or identification number	ADDS08828
Number of Individuals Covered	1429
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,563
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $118,763
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,563
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12157661

Policy instance

Insurance contract or identification number	12157661
Number of Individuals Covered	6708
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	7538
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-BTRM
Welfare Benefit Premiums Paid to Carrier	USD $1,062,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	2856
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-SDEP
Welfare Benefit Premiums Paid to Carrier	USD $404,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	3454
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-VOL
Welfare Benefit Premiums Paid to Carrier	USD $766,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	6330
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $150,562
Total amount of fees paid to insurance company	USD $71,167
Other welfare benefits provided	LTD-ABIL
Welfare Benefit Premiums Paid to Carrier	USD $2,390,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $150,562
Amount paid for insurance broker fees	71167
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008528507

Policy instance

Insurance contract or identification number	0008528507
Number of Individuals Covered	1073
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,060
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITILLNES, ISWL STND
Welfare Benefit Premiums Paid to Carrier	USD $233,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,288
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

676472G

Policy instance

Insurance contract or identification number	676472G
Number of Individuals Covered	1336
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $86,581
Total amount of fees paid to insurance company	USD $52,540
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,633,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $86,581
Amount paid for insurance broker fees	52540
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12157661

Policy instance

Insurance contract or identification number	12157661
Number of Individuals Covered	5427
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	6767
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-BTRM
Welfare Benefit Premiums Paid to Carrier	USD $1,109,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	2870
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-SDEP
Welfare Benefit Premiums Paid to Carrier	USD $413,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	1945
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-VOL
Welfare Benefit Premiums Paid to Carrier	USD $922,085
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	6369
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $153,220
Total amount of fees paid to insurance company	USD $51,014
Other welfare benefits provided	LTD-ABIL
Welfare Benefit Premiums Paid to Carrier	USD $2,662,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $153,220
Amount paid for insurance broker fees	51014

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008528507

Policy instance

Insurance contract or identification number	0008528507
Number of Individuals Covered	1216
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $12,737
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITILLNES, ISWL STND
Welfare Benefit Premiums Paid to Carrier	USD $231,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,963

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

676472G

Policy instance

Insurance contract or identification number	676472G
Number of Individuals Covered	1332
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $87,227
Total amount of fees paid to insurance company	USD $28,695
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,907,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $85,112
Amount paid for insurance broker fees	28695

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ADDS08828

Policy instance

Insurance contract or identification number	ADDS08828
Number of Individuals Covered	2850
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,787
Total amount of fees paid to insurance company	USD $325
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $92,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,787
Amount paid for insurance broker fees	325

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12157661

Policy instance

Insurance contract or identification number	12157661
Number of Individuals Covered	5370
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	7576
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-BTRM
Welfare Benefit Premiums Paid to Carrier	USD $1,066,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	2807
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-SDEP
Welfare Benefit Premiums Paid to Carrier	USD $391,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	2007
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-VOL
Welfare Benefit Premiums Paid to Carrier	USD $891,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	6268
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $145,553
Total amount of fees paid to insurance company	USD $75,596
Other welfare benefits provided	LTD-ABIL
Welfare Benefit Premiums Paid to Carrier	USD $2,502,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $145,553
Amount paid for insurance broker fees	73380
Additional information about fees paid to insurance broker	BONUS PAID

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008528507

Policy instance

Insurance contract or identification number	0008528507
Number of Individuals Covered	1339
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,682
Total amount of fees paid to insurance company	USD $4,388
Other welfare benefits provided	ACCIDENT, CRITILLNES, ISWL STND
Welfare Benefit Premiums Paid to Carrier	USD $271,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,589
Amount paid for insurance broker fees	4388
Additional information about fees paid to insurance broker	ADDITIONAL COMP.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

676472G

Policy instance

Insurance contract or identification number	676472G
Number of Individuals Covered	1301
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $77,043
Total amount of fees paid to insurance company	USD $38,749
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,568,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $77,043
Amount paid for insurance broker fees	37732
Additional information about fees paid to insurance broker	BONUS PAID

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ADDS08828

Policy instance

Insurance contract or identification number	ADDS08828
Number of Individuals Covered	2670
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,992
Total amount of fees paid to insurance company	USD $1,277
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $99,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,992
Amount paid for insurance broker fees	1277
Additional information about fees paid to insurance broker	BONUS PAID

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3336647

Policy instance

Insurance contract or identification number	3336647
Number of Individuals Covered	4
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12157661

Policy instance

Insurance contract or identification number	12157661
Number of Individuals Covered	4714
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	7144
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $330,883
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-BTRM
Welfare Benefit Premiums Paid to Carrier	USD $976,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $296,548

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	1964
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-VOL
Welfare Benefit Premiums Paid to Carrier	USD $1,067,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	2729
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-SDEP
Welfare Benefit Premiums Paid to Carrier	USD $433,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	6052
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LTD-ABIL
Welfare Benefit Premiums Paid to Carrier	USD $3,063,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008528507

Policy instance

Insurance contract or identification number	0008528507
Number of Individuals Covered	1456
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $17,113
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITILLNES, ISWL STND
Welfare Benefit Premiums Paid to Carrier	USD $301,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,733
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

676472G

Policy instance

Insurance contract or identification number	676472G
Number of Individuals Covered	1144
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $147,079
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,524,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $130,874

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

676472G

Policy instance

Insurance contract or identification number	676472G
Number of Individuals Covered	1004
Insurance policy start date	2017-08-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,838
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $94,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,838
Insurance broker name	HICKOK & BOARDMAN

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

120993

Policy instance

Insurance contract or identification number	120993
Number of Individuals Covered	13
Insurance policy start date	2017-01-01
Insurance policy end date	2017-08-01
Total amount of commissions paid to insurance broker	USD $93
Total amount of fees paid to insurance company	USD $11
Welfare Benefit Premiums Paid to Carrier	USD $553
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $93
Amount paid for insurance broker fees	10
Insurance broker organization code?	3
Insurance broker name	PROSENTIAL GROUP LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008528507

Policy instance

Insurance contract or identification number	0008528507
Number of Individuals Covered	1522
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $15,078
Total amount of fees paid to insurance company	USD $5,708
Other welfare benefits provided	ACCIDENT, CRITILLNES, ISWL STND
Welfare Benefit Premiums Paid to Carrier	USD $343,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,357
Amount paid for insurance broker fees	5708
Insurance broker organization code?	3
Insurance broker name	PANTALONE, JO, ANN

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	7551
Insurance policy start date	2017-08-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LTD-ABIL
Welfare Benefit Premiums Paid to Carrier	USD $115,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	218
Insurance policy start date	2017-08-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-VOL
Welfare Benefit Premiums Paid to Carrier	USD $71,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	2209
Insurance policy start date	2017-08-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-SDEP
Welfare Benefit Premiums Paid to Carrier	USD $35,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3336647

Policy instance

Insurance contract or identification number	3336647
Number of Individuals Covered	4
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

579370

Policy instance

Insurance contract or identification number	579370
Number of Individuals Covered	993
Insurance policy start date	2017-01-01
Insurance policy end date	2017-08-01
Total amount of commissions paid to insurance broker	USD $69,827
Total amount of fees paid to insurance company	USD $30,612
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,557,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $69,827
Amount paid for insurance broker fees	27262
Insurance broker organization code?	3
Insurance broker name	PROSENTIAL GROUP LLC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

558975

Policy instance

Insurance contract or identification number	558975
Number of Individuals Covered	5662
Insurance policy start date	2017-01-01
Insurance policy end date	2017-08-01
Total amount of commissions paid to insurance broker	USD $52,245
Total amount of fees paid to insurance company	USD $45,714
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,344,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,245
Amount paid for insurance broker fees	41029
Insurance broker organization code?	3
Insurance broker name	PROSENTIAL GROUP LLC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

586641

Policy instance

Insurance contract or identification number	586641
Number of Individuals Covered	5991
Insurance policy start date	2017-01-01
Insurance policy end date	2017-08-01
Total amount of commissions paid to insurance broker	USD $36,493
Total amount of fees paid to insurance company	USD $21,287
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,092,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,493
Amount paid for insurance broker fees	21287
Insurance broker organization code?	3
Insurance broker name	PROSENTIAL GROUP LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12157661

Policy instance

Insurance contract or identification number	12157661
Number of Individuals Covered	4738
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

681038G

Policy instance

Insurance contract or identification number	681038G
Number of Individuals Covered	6830
Insurance policy start date	2017-08-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,679
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFE-BTRM
Welfare Benefit Premiums Paid to Carrier	USD $33,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,679
Insurance broker name	HICKOK & BOARDMAN FINANCIAL PLANNIN

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3336647

Policy instance

Insurance contract or identification number	3336647
Number of Individuals Covered	4
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

579370

Policy instance

Insurance contract or identification number	579370
Number of Individuals Covered	944
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $118,377
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,061,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $82,297
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING&

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

558975

Policy instance

Insurance contract or identification number	558975
Number of Individuals Covered	7363
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $124,022
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,307,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $66,145
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

586641

Policy instance

Insurance contract or identification number	586641
Number of Individuals Covered	5936
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $71,596
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,507,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,219
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker name	HICKOK & BOARDMAN FINANCIAL PLANNIN

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12157661

Policy instance

Insurance contract or identification number	12157661
Number of Individuals Covered	4263
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

558975

Policy instance

Insurance contract or identification number	558975
Number of Individuals Covered	7266
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $120,166
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,204,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $64,089
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

579370

Policy instance

Insurance contract or identification number	579370
Number of Individuals Covered	907
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $90,523
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,577,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,921
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING&

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

586641

Policy instance

Insurance contract or identification number	586641
Number of Individuals Covered	5798
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $68,631
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,444,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,346
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker name	HICKOK & BOARDMAN FINANCIAL PLANNIN

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12157661

Policy instance

Insurance contract or identification number	12157661
Number of Individuals Covered	4067
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3336647

Policy instance

Insurance contract or identification number	3336647
Number of Individuals Covered	5
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3336647

Policy instance

Insurance contract or identification number	3336647
Number of Individuals Covered	3
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

579370

Policy instance

Insurance contract or identification number	579370
Number of Individuals Covered	892
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $64,215
Total amount of fees paid to insurance company	USD $28,170
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,609,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $64,215
Insurance broker organization code?	3
Amount paid for insurance broker fees	28170
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING&

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

586641

Policy instance

Insurance contract or identification number	586641
Number of Individuals Covered	5779
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $45,853
Total amount of fees paid to insurance company	USD $26,748
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,528,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,853
Amount paid for insurance broker fees	26748
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12157661

Policy instance

Insurance contract or identification number	12157661
Number of Individuals Covered	3977
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

558975

Policy instance

Insurance contract or identification number	558975
Number of Individuals Covered	7287
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $61,686
Total amount of fees paid to insurance company	USD $53,975
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,084,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,686
Insurance broker organization code?	3
Amount paid for insurance broker fees	53975
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12157661

Policy instance

Insurance contract or identification number	12157661
Number of Individuals Covered	3822
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

586641

Policy instance

Insurance contract or identification number	586641
Number of Individuals Covered	5592
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $45,711
Total amount of fees paid to insurance company	USD $26,665
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,633,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,711
Amount paid for insurance broker fees	26665
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

558975

Policy instance

Insurance contract or identification number	558975
Number of Individuals Covered	7083
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $50,872
Total amount of fees paid to insurance company	USD $44,512
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,543,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,872
Insurance broker organization code?	3
Amount paid for insurance broker fees	44512
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

579370

Policy instance

Insurance contract or identification number	579370
Number of Individuals Covered	864
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $56,110
Total amount of fees paid to insurance company	USD $24,914
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,383,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,110
Insurance broker organization code?	3
Amount paid for insurance broker fees	24914
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING&

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3213296

Policy instance

Insurance contract or identification number	3213296
Number of Individuals Covered	5
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3213296

Policy instance

Insurance contract or identification number	3213296
Number of Individuals Covered	5
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

579370

Policy instance

Insurance contract or identification number	579370
Number of Individuals Covered	850
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $57,130
Total amount of fees paid to insurance company	USD $17,900
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,432,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

586641

Policy instance

Insurance contract or identification number	586641
Number of Individuals Covered	5378
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $48,071
Total amount of fees paid to insurance company	USD $20,024
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,602,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

558975

Policy instance

Insurance contract or identification number	558975
Number of Individuals Covered	6886
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $48,499
Total amount of fees paid to insurance company	USD $30,312
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,424,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12157661

Policy instance

Insurance contract or identification number	12157661
Number of Individuals Covered	3684
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3213296

Policy instance

Insurance contract or identification number	3213296
Number of Individuals Covered	6
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

579370

Policy instance

Insurance contract or identification number	579370
Number of Individuals Covered	824
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $71,106
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,425,167
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,854
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING&

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

558975

Policy instance

Insurance contract or identification number	558975
Number of Individuals Covered	6910
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $72,831
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,427,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,554
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

586641

Policy instance

Insurance contract or identification number	586641
Number of Individuals Covered	5425
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $49,905
Total amount of fees paid to insurance company	USD $16,835
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,663,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,905
Amount paid for insurance broker fees	16835
Additional information about fees paid to insurance broker	ADDITIONAL PRODUCER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HICKOK BOARDMAN FINANCIAL PLANNING

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12157661

Policy instance

Insurance contract or identification number	12157661
Number of Individuals Covered	3442
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	THE UNIVERSITY OF VERMONT MEDICAL CENTER
Employer identification number (EIN):	030219309
NAIC Classification:	622000
NAIC Description:	Hospitals