401k Plan data: BLUE MANTIS INC BENEFIT PLAN plan

BLUE MANTIS INC BENEFIT PLAN 401k Plan overview

Plan Name	BLUE MANTIS INC BENEFIT PLAN
Plan identification number	505

BLUE MANTIS INC BENEFIT PLAN 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 Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

BLUE MANTIS, INC has sponsored the creation of one or more 401k plans.

Company Name: BLUE MANTIS, INC

Employer identification number (EIN): 010504323

NAIC Classification: 541519
NAIC Description: Other Computer Related Services

Additional information about BLUE MANTIS, INC

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 2576858

More information about BLUE MANTIS, INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLUE MANTIS INC BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2023-01-01 ERIN JORDAN 2024-09-26
505 2022-01-01 ERIN JORDAN 2024-09-19
505 2021-01-01 JEANNE RANEY 2022-07-11
505 2020-01-01 JEANNE RANEY 2021-06-30
505 2019-01-01
505 2019-01-01
505 2018-01-01
505 2017-01-01 MICHELLE ANDERSON MICHELLE ANDERSON 2018-09-25

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
505	2023-01-01	ERIN JORDAN	2024-09-26
505	2022-01-01	ERIN JORDAN	2024-09-19
505	2021-01-01	JEANNE RANEY	2022-07-11
505	2020-01-01	JEANNE RANEY	2021-06-30
505	2019-01-01
505	2019-01-01
505	2018-01-01
505	2017-01-01	MICHELLE ANDERSON		MICHELLE ANDERSON	2018-09-25

Plan Statistics for BLUE MANTIS INC BENEFIT PLAN

401k plan membership statisitcs for BLUE MANTIS INC BENEFIT PLAN

Measure Date Value
2023: BLUE MANTIS INC BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 229
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 251
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 251
Number of employers contributing to the scheme 2023-01-01 0
2022: BLUE MANTIS INC BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 208
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 229
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 229
Number of employers contributing to the scheme 2022-01-01 0
2021: BLUE MANTIS INC BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 177
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 208
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 208
Number of employers contributing to the scheme 2021-01-01 0
2020: BLUE MANTIS INC BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 168
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 177
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 177
Number of employers contributing to the scheme 2020-01-01 0
2019: BLUE MANTIS INC BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 148
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 168
Total of all active and inactive participants 2019-01-01 168
Total participants 2019-01-01 168
2018: BLUE MANTIS INC BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 154
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 175
Total of all active and inactive participants 2018-01-01 175
Total participants 2018-01-01 175
2017: BLUE MANTIS INC BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 154
Total of all active and inactive participants 2017-01-01 154
Total participants 2017-01-01 154

Measure	Date	Value
2023: BLUE MANTIS INC BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	229
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	251
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	251
Number of employers contributing to the scheme	2023-01-01	0
2022: BLUE MANTIS INC BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	208
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	229
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	229
Number of employers contributing to the scheme	2022-01-01	0
2021: BLUE MANTIS INC BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	177
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	208
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	208
Number of employers contributing to the scheme	2021-01-01	0
2020: BLUE MANTIS INC BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	168
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	177
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	177
Number of employers contributing to the scheme	2020-01-01	0
2019: BLUE MANTIS INC BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	148
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	168
Total of all active and inactive participants	2019-01-01	168
Total participants	2019-01-01	168
2018: BLUE MANTIS INC BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	154
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	175
Total of all active and inactive participants	2018-01-01	175
Total participants	2018-01-01	175
2017: BLUE MANTIS INC BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	154
Total of all active and inactive participants	2017-01-01	154
Total participants	2017-01-01	154

Form 5500 Responses for BLUE MANTIS INC BENEFIT PLAN

2023: BLUE MANTIS INC BENEFIT PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: BLUE MANTIS INC BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: BLUE MANTIS INC BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: BLUE MANTIS INC BENEFIT PLAN 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 benefit arrangement – Insurance	Yes
2019: BLUE MANTIS INC BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	Yes
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: BLUE MANTIS INC BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: BLUE MANTIS INC BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	First time form 5500 has been submitted	Yes
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BYZS

Policy instance

Insurance contract or identification number	GLUG0BYZS
Number of Individuals Covered	251
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $10,583
Total amount of fees paid to insurance company	USD $14,820
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $146,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3899051

Policy instance

Insurance contract or identification number	E3899051
Number of Individuals Covered	12
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $850
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $5,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98426261001

Policy instance

Insurance contract or identification number	98426261001
Number of Individuals Covered	327
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,625
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,743
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

624423

Policy instance

Insurance contract or identification number	624423
Number of Individuals Covered	312
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,178
Total amount of fees paid to insurance company	USD $83,548
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,989,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

624423

Policy instance

Insurance contract or identification number	624423
Number of Individuals Covered	294
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,142
Total amount of fees paid to insurance company	USD $70,810
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,609,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,142
Amount paid for insurance broker fees	70810
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98426261001

Policy instance

Insurance contract or identification number	98426261001
Number of Individuals Covered	296
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,779
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,779
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3899051

Policy instance

Insurance contract or identification number	E3899051
Number of Individuals Covered	13
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $981
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $6,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $682
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BYZS

Policy instance

Insurance contract or identification number	GLUG0BYZS
Number of Individuals Covered	229
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,638
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $119,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,638
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

624423

Policy instance

Insurance contract or identification number	624423
Number of Individuals Covered	241
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $92,381
Total amount of fees paid to insurance company	USD $742
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,292,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $77,931
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98426261001

Policy instance

Insurance contract or identification number	98426261001
Number of Individuals Covered	251
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,527
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,218
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3899051

Policy instance

Insurance contract or identification number	E3899051
Number of Individuals Covered	15
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,061
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $6,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $708
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD610150

Policy instance

Insurance contract or identification number	SGD610150
Number of Individuals Covered	208
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $488
Total amount of fees paid to insurance company	USD $3,541
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $488
Amount paid for insurance broker fees	3541
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM609479

Policy instance

Insurance contract or identification number	SGM609479
Number of Individuals Covered	177
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $11,826
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $146,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $11,826
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3899051

Policy instance

Insurance contract or identification number	E3899051
Number of Individuals Covered	15
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,376
Total amount of fees paid to insurance company	USD $6
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $8,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $837
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98426261001

Policy instance

Insurance contract or identification number	98426261001
Number of Individuals Covered	195
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,283
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,283
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

624423

Policy instance

Insurance contract or identification number	624423
Number of Individuals Covered	228
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $96,009
Total amount of fees paid to insurance company	USD $960
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,362,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $96,009
Amount paid for insurance broker fees	960
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3899051

Policy instance

Insurance contract or identification number	E3899051
Number of Individuals Covered	16
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,468
Total amount of fees paid to insurance company	USD $44
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $702
Insurance broker organization code?	3
Amount paid for insurance broker fees	1

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM609479

Policy instance

Insurance contract or identification number	SGM609479
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,004
Total amount of fees paid to insurance company	USD $957
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,004
Amount paid for insurance broker fees	957
Additional information about fees paid to insurance broker	OVERIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD610150

Policy instance

Insurance contract or identification number	SGD610150
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,421
Total amount of fees paid to insurance company	USD $1,294
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $3,421
Amount paid for insurance broker fees	1294
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD610149

Policy instance

Insurance contract or identification number	SGD610149
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,839
Total amount of fees paid to insurance company	USD $908
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,839
Amount paid for insurance broker fees	908
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD600816

Policy instance

Insurance contract or identification number	NYD600816
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98426261001

Policy instance

Insurance contract or identification number	98426261001
Number of Individuals Covered	221
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,173
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,173
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00624423

Policy instance

Insurance contract or identification number	00624423
Number of Individuals Covered	151
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $87,578
Total amount of fees paid to insurance company	USD $4,930
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,155,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $87,578
Amount paid for insurance broker fees	4930
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM609479

Policy instance

Insurance contract or identification number	SGM609479
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,004
Total amount of fees paid to insurance company	USD $957
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,004
Amount paid for insurance broker fees	957
Additional information about fees paid to insurance broker	OVERIDE
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD600816

Policy instance

Insurance contract or identification number	NYD600816
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98426261001

Policy instance

Insurance contract or identification number	98426261001
Number of Individuals Covered	221
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,173
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,173
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00624423

Policy instance

Insurance contract or identification number	00624423
Number of Individuals Covered	151
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $87,578
Total amount of fees paid to insurance company	USD $4,930
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,155,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $87,578
Amount paid for insurance broker fees	4930
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK607065

Policy instance

Insurance contract or identification number	SOK607065
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $317
Total amount of fees paid to insurance company	USD $120
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $317
Amount paid for insurance broker fees	120
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD610150

Policy instance

Insurance contract or identification number	SGD610150
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,421
Total amount of fees paid to insurance company	USD $1,294
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $3,421
Amount paid for insurance broker fees	1294
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD610149

Policy instance

Insurance contract or identification number	SGD610149
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,839
Total amount of fees paid to insurance company	USD $908
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,839
Amount paid for insurance broker fees	908
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3899051

Policy instance

Insurance contract or identification number	E3899051
Number of Individuals Covered	16
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,468
Total amount of fees paid to insurance company	USD $44
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $702
Insurance broker organization code?	3
Amount paid for insurance broker fees	1

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000061469

Policy instance

Insurance contract or identification number	000061469
Number of Individuals Covered	336
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,207
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $148,149
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,546
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98426261001

Policy instance

Insurance contract or identification number	98426261001
Number of Individuals Covered	196
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,196
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,196
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

9572

Policy instance

Insurance contract or identification number	9572
Number of Individuals Covered	158
Insurance policy start date	2018-02-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $7,489
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $84,605
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,489
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3899051

Policy instance

Insurance contract or identification number	E3899051
Number of Individuals Covered	14
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $951
Total amount of fees paid to insurance company	USD $113
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $511
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

017082

Policy instance

Insurance contract or identification number	017082
Number of Individuals Covered	121
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $13,266
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,266
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

056432

Policy instance

Insurance contract or identification number	056432
Number of Individuals Covered	162
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $20,351
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,351
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

072118

Policy instance

Insurance contract or identification number	072118
Number of Individuals Covered	59
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,364
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,364
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

072119

Policy instance

Insurance contract or identification number	072119
Number of Individuals Covered	19
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,666
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,666
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98426261001

Policy instance

Insurance contract or identification number	98426261001
Number of Individuals Covered	184
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,127
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,127
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS INC

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000061469

Policy instance

Insurance contract or identification number	000061469
Number of Individuals Covered	337
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $8,536
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $151,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,791
Insurance broker organization code?	3
Insurance broker name	COMBINED SERVICES LLC

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

056432

Policy instance

Insurance contract or identification number	056432
Number of Individuals Covered	287
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $30,207
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,244,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,207
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS INC

HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )

Policy contract number

081736

Policy instance

Insurance contract or identification number	081736
Number of Individuals Covered	40
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,832
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $322,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,832
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS INC

HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )

Policy contract number

017108

Policy instance

Insurance contract or identification number	017108
Number of Individuals Covered	51
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,687
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $234,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,687
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS INC

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

9572

Policy instance

Insurance contract or identification number	9572
Number of Individuals Covered	146
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,783
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $88,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,783
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS INC

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Company Name:	BLUE MANTIS, INC
Employer identification number (EIN):	010504323
NAIC Classification:	541519
NAIC Description:	Other Computer Related Services

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	2576858