401k Plan data: MCDEVITT COMPANIES WELFARE BENEFIT PLAN plan

MCDEVITT COMPANIES WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	MCDEVITT COMPANIES WELFARE BENEFIT PLAN
Plan identification number	502

MCDEVITT COMPANIES WELFARE 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) Other welfare benefit cover Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

MCDEVITT TRUCKS, INC. has sponsored the creation of one or more 401k plans.

Company Name: MCDEVITT TRUCKS, INC.

Employer identification number (EIN): 020312174

NAIC Classification: 441228
NAIC Description: Motorcycle, ATV, and All Other Motor Vehicle Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MCDEVITT COMPANIES WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2018-12-01
502 2017-12-01 RILINDA SIEGEL 2019-09-03
502 2016-12-01
502 2016-01-01
502 2015-01-01
502 2014-01-01
502 2013-01-01
502 2012-01-01 RILINDA SIEGEL
502 2011-01-01 DAVE CLOUGH
502 2010-01-01 ROSAMOND CAIN
502 2009-01-01 ROSAMOND CAIN
502 2009-01-01 ROSAMOND CAIN
502 2009-01-01 ROSAMOND CAIN

Plan Statistics for MCDEVITT COMPANIES WELFARE BENEFIT PLAN

401k plan membership statisitcs for MCDEVITT COMPANIES WELFARE BENEFIT PLAN

Measure Date Value
2018: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-12-01 145
Total number of active participants reported on line 7a of the Form 5500 2018-12-01 74
Number of retired or separated participants receiving benefits 2018-12-01 0
Number of other retired or separated participants entitled to future benefits 2018-12-01 0
Total of all active and inactive participants 2018-12-01 74
2017: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-12-01 153
Total number of active participants reported on line 7a of the Form 5500 2017-12-01 116
Total of all active and inactive participants 2017-12-01 116
2016: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-12-01 155
Total number of active participants reported on line 7a of the Form 5500 2016-12-01 153
Total of all active and inactive participants 2016-12-01 153
Total participants, beginning-of-year 2016-01-01 162
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 155
Total of all active and inactive participants 2016-01-01 155
2015: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 155
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 162
Total of all active and inactive participants 2015-01-01 162
2014: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 108
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 155
Total of all active and inactive participants 2014-01-01 155
2013: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 108
Total of all active and inactive participants 2013-01-01 108
2012: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 121
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 109
Total of all active and inactive participants 2012-01-01 109
Total participants 2012-01-01 0
2011: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 160
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 121
Total of all active and inactive participants 2011-01-01 121
2010: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 154
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 160
Total of all active and inactive participants 2010-01-01 160
Total participants 2010-01-01 160
2009: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 158
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 154
Total of all active and inactive participants 2009-01-01 154
Total participants 2009-01-01 154

Measure	Date	Value
2018: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-12-01	145
Total number of active participants reported on line 7a of the Form 5500	2018-12-01	74
Number of retired or separated participants receiving benefits	2018-12-01	0
Number of other retired or separated participants entitled to future benefits	2018-12-01	0
Total of all active and inactive participants	2018-12-01	74
2017: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-12-01	153
Total number of active participants reported on line 7a of the Form 5500	2017-12-01	116
Total of all active and inactive participants	2017-12-01	116
2016: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-12-01	155
Total number of active participants reported on line 7a of the Form 5500	2016-12-01	153
Total of all active and inactive participants	2016-12-01	153
Total participants, beginning-of-year	2016-01-01	162
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	155
Total of all active and inactive participants	2016-01-01	155
2015: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	155
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	162
Total of all active and inactive participants	2015-01-01	162
2014: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	108
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	155
Total of all active and inactive participants	2014-01-01	155
2013: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	108
Total of all active and inactive participants	2013-01-01	108
2012: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	109
Total of all active and inactive participants	2012-01-01	109
Total participants	2012-01-01	0
2011: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	160
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	121
Total of all active and inactive participants	2011-01-01	121
2010: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	154
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	160
Total of all active and inactive participants	2010-01-01	160
Total participants	2010-01-01	160
2009: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	158
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	154
Total of all active and inactive participants	2009-01-01	154
Total participants	2009-01-01	154

Form 5500 Responses for MCDEVITT COMPANIES WELFARE BENEFIT PLAN

2018: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-12-01	Type of plan entity	Single employer plan
2018-12-01	Submission has been amended	No
2018-12-01	This submission is the final filing	No
2018-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-12-01	Plan is a collectively bargained plan	No
2018-12-01	Plan funding arrangement – Insurance	Yes
2018-12-01	Plan benefit arrangement – Insurance	Yes
2017: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-12-01	Type of plan entity	Single employer plan
2017-12-01	Plan funding arrangement – Insurance	Yes
2017-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-12-01	Plan benefit arrangement – Insurance	Yes
2017-12-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-12-01	Type of plan entity	Single employer plan
2016-12-01	Plan funding arrangement – Insurance	Yes
2016-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-12-01	Plan benefit arrangement – Insurance	Yes
2016-12-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
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: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 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: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 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: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 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: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 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: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
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: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 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: MCDEVITT COMPANIES WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
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

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

Policy contract number

30036396

Policy instance

Insurance contract or identification number	30036396
Number of Individuals Covered	77
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $910
Total amount of fees paid to insurance company	USD $0
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 $16,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $910
Insurance broker organization code?	3

NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 )

Policy contract number

000010925

Policy instance

Insurance contract or identification number	000010925
Number of Individuals Covered	123
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $4,040
Total amount of fees paid to insurance company	USD $0
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 $72,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $784
Insurance broker organization code?	3

MATTHEW THORNTON HEALTH PLAN INC. (National Association of Insurance Commissioners NAIC id number: 95527 )

Policy contract number

G1822

Policy instance

Insurance contract or identification number	G1822
Number of Individuals Covered	106
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $25,024
Total amount of fees paid to insurance company	USD $6,400
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 $785,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,024
Amount paid for insurance broker fees	6400
Additional information about fees paid to insurance broker	INCENTIVES, EDUCATION, COMMUNICATION AND TRAINING
Insurance broker organization code?	3

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

Policy contract number

903650

Policy instance

Insurance contract or identification number	903650
Number of Individuals Covered	80
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $8,225
Total amount of fees paid to insurance company	USD $0
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
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $74,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,225
Insurance broker organization code?	3

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

Policy contract number

30036396

Policy instance

Insurance contract or identification number	30036396
Number of Individuals Covered	131
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,010
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 )

Policy contract number

000010925

Policy instance

Insurance contract or identification number	000010925
Number of Individuals Covered	207
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $8,051
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $146,240
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

US FIRE (National Association of Insurance Commissioners NAIC id number: 21113 )

Policy contract number

US952448

Policy instance

Insurance contract or identification number	US952448
Number of Individuals Covered	172
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
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
Welfare Benefit Premiums Paid to Carrier	USD $457,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

903650

Policy instance

Insurance contract or identification number	903650
Number of Individuals Covered	193
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $11,045
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $112,453
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

30036396

Policy instance

Insurance contract or identification number	30036396
Number of Individuals Covered	132
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,121
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,121
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY

NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 )

Policy contract number

000010925

Policy instance

Insurance contract or identification number	000010925
Number of Individuals Covered	306
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,191
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $162,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,903
Insurance broker organization code?	3
Insurance broker name	COMBINED SERVICES LLC

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00508160

Policy instance

Insurance contract or identification number	00508160
Number of Individuals Covered	148
Insurance policy start date	2015-01-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $68,264
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $423,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $68,264
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

405800-0010

Policy instance

Insurance contract or identification number	405800-0010
Number of Individuals Covered	142
Insurance policy start date	2015-12-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,212
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
Commission paid to Insurance Broker	USD $6,212
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY

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

Policy contract number

140903

Policy instance

Insurance contract or identification number	140903
Number of Individuals Covered	35
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $4,911
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,911
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY

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

Policy contract number

137159

Policy instance

Insurance contract or identification number	137159
Number of Individuals Covered	195
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $7,002
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $60,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,002
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY

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

Policy contract number

137160

Policy instance

Insurance contract or identification number	137160
Number of Individuals Covered	35
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $3,101
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE ADD, LIFESTYLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $18,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,101
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY

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

Policy contract number

085861500

Policy instance

Insurance contract or identification number	085861500
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,860
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
Welfare Benefit Premiums Paid to Carrier	USD $109,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,860
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY INC

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

Policy contract number

0858611000

Policy instance

Insurance contract or identification number	0858611000
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,614
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
Welfare Benefit Premiums Paid to Carrier	USD $358,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,614
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY

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

Policy contract number

0858612000

Policy instance

Insurance contract or identification number	0858612000
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,281
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
Welfare Benefit Premiums Paid to Carrier	USD $149,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,281
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY

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

Policy contract number

858623000

Policy instance

Insurance contract or identification number	858623000
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $583
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
Welfare Benefit Premiums Paid to Carrier	USD $16,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $583
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY

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

Policy contract number

0858621000

Policy instance

Insurance contract or identification number	0858621000
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,568
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
Welfare Benefit Premiums Paid to Carrier	USD $44,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,568
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858622000

Policy instance

Insurance contract or identification number	0858622000
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,528
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
Welfare Benefit Premiums Paid to Carrier	USD $43,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,528
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858633000

Policy instance

Insurance contract or identification number	0858633000
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $603
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
Welfare Benefit Premiums Paid to Carrier	USD $17,071
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $603
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858635000

Policy instance

Insurance contract or identification number	0858635000
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $216
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
Welfare Benefit Premiums Paid to Carrier	USD $6,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $216
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858631000

Policy instance

Insurance contract or identification number	0858631000
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,116
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
Welfare Benefit Premiums Paid to Carrier	USD $59,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,116
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858632000

Policy instance

Insurance contract or identification number	0858632000
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,718
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
Welfare Benefit Premiums Paid to Carrier	USD $76,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,718
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 )

Policy contract number

000010925

Policy instance

Insurance contract or identification number	000010925
Number of Individuals Covered	284
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,606
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,802
Insurance broker organization code?	3
Insurance broker name	COMBINED SERVICES LLC

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

Policy contract number

137160

Policy instance

Insurance contract or identification number	137160
Number of Individuals Covered	36
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $1,805
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	ADD
Welfare Benefit Premiums Paid to Carrier	USD $11,913
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,805
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY

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

Policy contract number

0858613000

Policy instance

Insurance contract or identification number	0858613000
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,588
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
Welfare Benefit Premiums Paid to Carrier	USD $129,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,588
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

137159

Policy instance

Insurance contract or identification number	137159
Number of Individuals Covered	190
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $4,868
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $44,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,868
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY INC

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

Policy contract number

30036396

Policy instance

Insurance contract or identification number	30036396
Number of Individuals Covered	122
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $784
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
Welfare Benefit Premiums Paid to Carrier	USD $10,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $784
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY

NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 )

Policy contract number

000010925

Policy instance

Insurance contract or identification number	000010925
Number of Individuals Covered	185
Insurance policy start date	2013-12-01
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,006
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

137160

Policy instance

Insurance contract or identification number	137160
Number of Individuals Covered	28
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $1,907
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	ADD
Welfare Benefit Premiums Paid to Carrier	USD $12,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $951
Insurance broker organization code?	3
Insurance broker name	HAYS BENEFITS GROUP LLC

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

Policy contract number

0858613000

Policy instance

Insurance contract or identification number	0858613000
Number of Individuals Covered	23
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $683
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
Welfare Benefit Premiums Paid to Carrier	USD $12,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $683
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY

MATTHEW THORNTON HEALTH PLAN INC. (National Association of Insurance Commissioners NAIC id number: 95527 )

Policy contract number

364041

Policy instance

Insurance contract or identification number	364041
Number of Individuals Covered	97
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $38,187
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
Welfare Benefit Premiums Paid to Carrier	USD $1,030,429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,187
Insurance broker name	NEW HAMPSHIRE AUTO DEALERS SERVICES

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

Policy contract number

137159

Policy instance

Insurance contract or identification number	137159
Number of Individuals Covered	123
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $5,240
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $50,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,495
Insurance broker organization code?	3
Insurance broker name	HAYS BENEFITS GROUP LLC

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

Policy contract number

30036396

Policy instance

Insurance contract or identification number	30036396
Number of Individuals Covered	88
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $771
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
Welfare Benefit Premiums Paid to Carrier	USD $10,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $472
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP

NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 )

Policy contract number

000003391

Policy instance

Insurance contract or identification number	000003391
Number of Individuals Covered	187
Insurance policy start date	2013-01-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $1,248
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $83,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,061
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

0858611000

Policy instance

Insurance contract or identification number	0858611000
Number of Individuals Covered	71
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,822
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
Welfare Benefit Premiums Paid to Carrier	USD $33,810
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,822
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

085861500

Policy instance

Insurance contract or identification number	085861500
Number of Individuals Covered	17
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $492
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
Welfare Benefit Premiums Paid to Carrier	USD $9,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $492
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858631000

Policy instance

Insurance contract or identification number	0858631000
Number of Individuals Covered	10
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $228
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
Welfare Benefit Premiums Paid to Carrier	USD $4,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $228
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858635000

Policy instance

Insurance contract or identification number	0858635000
Number of Individuals Covered	2
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $61
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
Welfare Benefit Premiums Paid to Carrier	USD $1,133
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
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858632000

Policy instance

Insurance contract or identification number	0858632000
Number of Individuals Covered	15
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $338
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
Welfare Benefit Premiums Paid to Carrier	USD $6,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $338
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858633000

Policy instance

Insurance contract or identification number	0858633000
Number of Individuals Covered	3
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $84
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
Welfare Benefit Premiums Paid to Carrier	USD $1,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858622000

Policy instance

Insurance contract or identification number	0858622000
Number of Individuals Covered	11
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $233
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
Welfare Benefit Premiums Paid to Carrier	USD $4,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $233
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858621000

Policy instance

Insurance contract or identification number	0858621000
Number of Individuals Covered	8
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $217
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
Welfare Benefit Premiums Paid to Carrier	USD $4,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $217
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

858623000

Policy instance

Insurance contract or identification number	858623000
Number of Individuals Covered	3
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $81
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
Welfare Benefit Premiums Paid to Carrier	USD $1,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $81
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

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

Policy contract number

0858612000

Policy instance

Insurance contract or identification number	0858612000
Number of Individuals Covered	27
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $731
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
Welfare Benefit Premiums Paid to Carrier	USD $13,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $731
Insurance broker organization code?	3
Insurance broker name	ROWLEY AGENCY INC

MATTHEW THORNTON HEALTH PLAN INC. (National Association of Insurance Commissioners NAIC id number: 95527 )

Policy contract number

364041

Policy instance

Insurance contract or identification number	364041
Number of Individuals Covered	101
Insurance policy start date	2012-11-01
Insurance policy end date	2012-12-31
Welfare Benefit Premiums Paid to Carrier	USD $176,783
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

137159

Policy instance

Insurance contract or identification number	137159
Number of Individuals Covered	128
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $5,926
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $48,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $979
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP INC DBA HAYS CO

NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 )

Policy contract number

000003391

Policy instance

Insurance contract or identification number	000003391
Number of Individuals Covered	198
Insurance policy start date	2012-11-01
Insurance policy end date	2012-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00461805

Policy instance

Insurance contract or identification number	00461805
Number of Individuals Covered	90
Insurance policy start date	2012-01-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $2,764
Total amount of fees paid to insurance company	USD $1,666
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,039
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
Insurance broker organization code?	3
Amount paid for insurance broker fees	1666
Insurance broker name	THE HAYS GROUP INC

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

Policy contract number

30036396

Policy instance

Insurance contract or identification number	30036396
Number of Individuals Covered	89
Insurance policy start date	2012-11-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $185
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,846
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $185
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP

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

Policy contract number

220231

Policy instance

Insurance contract or identification number	220231
Number of Individuals Covered	96
Insurance policy start date	2012-01-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $39,363
Welfare Benefit Premiums Paid to Carrier	USD $217,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,363
Insurance broker name	HAYS GROUP INC.

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00461805

Policy instance

Insurance contract or identification number	00461805
Number of Individuals Covered	96
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,144
Total amount of fees paid to insurance company	USD $644
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	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 $87,647

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

Policy contract number

137159

Policy instance

Insurance contract or identification number	137159
Number of Individuals Covered	121
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,746
Total amount of fees paid to insurance company	USD $585
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $46,774

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

Policy contract number

137160

Policy instance

Insurance contract or identification number	137160
Number of Individuals Covered	30
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,624
Total amount of fees paid to insurance company	USD $135
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,828

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

Policy contract number

140903

Policy instance

Insurance contract or identification number	140903
Number of Individuals Covered	21
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,696
Total amount of fees paid to insurance company	USD $384
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	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 $21,576

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

Policy contract number

12059932

Policy instance

Insurance contract or identification number	12059932
Insurance policy start date	2010-01-01
Insurance policy end date	2010-11-01
Total amount of fees paid to insurance company	USD $887
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	887
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-302923

Policy instance

Insurance contract or identification number	010-302923
Number of Individuals Covered	235
Insurance policy start date	2010-01-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $3,013
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $3,013
Insurance broker name	THE ROWLEY AGENCY

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00461805

Policy instance

Insurance contract or identification number	00461805
Number of Individuals Covered	117
Insurance policy start date	2010-11-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,505
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,101
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,505
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY, INC.

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

400544

Policy instance

Insurance contract or identification number	400544
Number of Individuals Covered	263
Insurance policy start date	2010-01-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $68,721
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $902,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $68,721
Insurance broker organization code?	3
Insurance broker name	THE ROWLEY AGENCY, INC.

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Company Name:	MCDEVITT TRUCKS, INC.
Employer identification number (EIN):	020312174
NAIC Classification:	441228
NAIC Description:	Motorcycle, ATV, and All Other Motor Vehicle Dealers

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