401k Plan data: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN plan

LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN
Plan identification number	501

LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

LACONIA CLINIC has sponsored the creation of one or more 401k plans.

Company Name: LACONIA CLINIC

Employer identification number (EIN): 020460192

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-01-01 JUDY LAFRANCE
501 2015-01-01 JUDY LAFRANCE
501 2014-01-01 ANDREW PATTERSON
501 2013-01-01 ANDREW PATTERSON
501 2012-01-01 ANDREW PATTERSON
501 2011-01-01 ANDREW PATTERSON
501 2009-01-01 ANDREW PATTERSON

Plan id#	Filing Submission Date	Name of Administrator
501	2016-01-01	JUDY LAFRANCE
501	2015-01-01	JUDY LAFRANCE
501	2014-01-01	ANDREW PATTERSON
501	2013-01-01	ANDREW PATTERSON
501	2012-01-01	ANDREW PATTERSON
501	2011-01-01	ANDREW PATTERSON
501	2009-01-01	ANDREW PATTERSON

Plan Statistics for LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN

Measure Date Value
2016: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 104
Total of all active and inactive participants 2016-01-01 104
2015: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 252
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 129
Total of all active and inactive participants 2015-01-01 129
2014: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 240
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 252
Total of all active and inactive participants 2014-01-01 252
2013: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 269
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 240
Total of all active and inactive participants 2013-01-01 240
2012: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 269
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 269
Total of all active and inactive participants 2012-01-01 269
2011: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 229
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 269
Total of all active and inactive participants 2011-01-01 269
2009: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 191
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 203
Total of all active and inactive participants 2009-01-01 203
Total participants 2009-01-01 203

Measure	Date	Value
2016: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	104
Total of all active and inactive participants	2016-01-01	104
2015: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	252
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	129
Total of all active and inactive participants	2015-01-01	129
2014: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	240
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	252
Total of all active and inactive participants	2014-01-01	252
2013: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	269
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	240
Total of all active and inactive participants	2013-01-01	240
2012: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	269
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	269
Total of all active and inactive participants	2012-01-01	269
2011: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	229
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	269
Total of all active and inactive participants	2011-01-01	269
2009: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	191
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	203
Total of all active and inactive participants	2009-01-01	203
Total participants	2009-01-01	203

Form 5500 Responses for LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN

2016: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: LACONIA CLINIC, P.C. HEALTH AND WELFARE 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: LACONIA CLINIC, P.C. HEALTH AND WELFARE 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: LACONIA CLINIC, P.C. HEALTH AND WELFARE 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: LACONIA CLINIC, P.C. HEALTH AND WELFARE 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: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: LACONIA CLINIC, P.C. HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

555738

Policy instance

Insurance contract or identification number	555738
Number of Individuals Covered	45
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,808
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $18,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,808
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1040716

Policy instance

Insurance contract or identification number	1040716
Number of Individuals Covered	189
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,467
Total amount of fees paid to insurance company	USD $6,511
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $130,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,467
Amount paid for insurance broker fees	6511
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

HARVARD PILGRIM HEALTH CARE OF NE, INC. (National Association of Insurance Commissioners NAIC id number: 96917 )

Policy contract number

87053

Policy instance

Insurance contract or identification number	87053
Number of Individuals Covered	173
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $28,463
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,063,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,463
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

080510

Policy instance

Insurance contract or identification number	080510
Number of Individuals Covered	57
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $11,527
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $430,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,527
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

505767

Policy instance

Insurance contract or identification number	505767
Number of Individuals Covered	21
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,562
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,562
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

HR CONCEPTS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Number of Individuals Covered	48
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $104
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	FSA/DCA
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $104
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

505767

Policy instance

Insurance contract or identification number	505767
Number of Individuals Covered	21
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,223
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,223
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

080510

Policy instance

Insurance contract or identification number	080510
Number of Individuals Covered	47
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,232
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $351,535
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,232
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

87053

Policy instance

Insurance contract or identification number	87053
Number of Individuals Covered	205
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $31,451
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,197,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,451
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1040716

Policy instance

Insurance contract or identification number	1040716
Number of Individuals Covered	201
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $8,441
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
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $135,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,441
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

555738

Policy instance

Insurance contract or identification number	555738
Number of Individuals Covered	48
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,071
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	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $31,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,071
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

HR CONCEPTS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Number of Individuals Covered	51
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $111
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
Other welfare benefits provided	FSA/DCA
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $111
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

505767

Policy instance

Insurance contract or identification number	505767
Number of Individuals Covered	25
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,715
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,715
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

055438

Policy instance

Insurance contract or identification number	055438
Number of Individuals Covered	45
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,471
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $352,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,471
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

H07709

Policy instance

Insurance contract or identification number	H07709
Number of Individuals Covered	152
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,426
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
Welfare Benefit Premiums Paid to Carrier	USD $73,063
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,426
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

555738

Policy instance

Insurance contract or identification number	555738
Number of Individuals Covered	50
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,662
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	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $26,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,662
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

000003666

Policy instance

Insurance contract or identification number	000003666
Number of Individuals Covered	107
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,396
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 $53,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,736
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

022162

Policy instance

Insurance contract or identification number	022162
Number of Individuals Covered	195
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $30,177
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,123,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,177
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

555738

Policy instance

Insurance contract or identification number	555738
Number of Individuals Covered	46
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,314
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	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $26,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,314
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

505767

Policy instance

Insurance contract or identification number	505767
Number of Individuals Covered	27
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,719
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,719
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

055438

Policy instance

Insurance contract or identification number	055438
Number of Individuals Covered	49
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $10,206
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $375,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,206
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

022162

Policy instance

Insurance contract or identification number	022162
Number of Individuals Covered	220
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $32,790
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,210,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,790
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

H07709

Policy instance

Insurance contract or identification number	H07709
Number of Individuals Covered	173
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,366
Total amount of fees paid to insurance company	USD $427
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
Welfare Benefit Premiums Paid to Carrier	USD $70,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,366
Amount paid for insurance broker fees	427
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

000003666

Policy instance

Insurance contract or identification number	000003666
Number of Individuals Covered	138
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,861
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 $62,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,117
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

555738

Policy instance

Insurance contract or identification number	555738
Number of Individuals Covered	56
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,309
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	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $31,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

H07709

Policy instance

Insurance contract or identification number	H07709
Number of Individuals Covered	150
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,157
Total amount of fees paid to insurance company	USD $436
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
Welfare Benefit Premiums Paid to Carrier	USD $65,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

022162

Policy instance

Insurance contract or identification number	022162
Number of Individuals Covered	219
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $30,779
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,137,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

055438

Policy instance

Insurance contract or identification number	055438
Number of Individuals Covered	50
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $9,209
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $347,861
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

000003666

Policy instance

Insurance contract or identification number	000003666
Number of Individuals Covered	156
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,757
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 $61,431
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

505767

Policy instance

Insurance contract or identification number	505767
Number of Individuals Covered	26
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,758
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,646
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

505767

Policy instance

Insurance contract or identification number	505767
Number of Individuals Covered	30
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,734
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,734
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

055437

Policy instance

Insurance contract or identification number	055437
Number of Individuals Covered	0
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $25,203
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $841,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,203
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

022162

Policy instance

Insurance contract or identification number	022162
Number of Individuals Covered	229
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,242
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $297,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,242
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

H07709

Policy instance

Insurance contract or identification number	H07709
Number of Individuals Covered	151
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,220
Total amount of fees paid to insurance company	USD $557
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
Welfare Benefit Premiums Paid to Carrier	USD $67,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,220
Amount paid for insurance broker fees	557
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

555738

Policy instance

Insurance contract or identification number	555738
Number of Individuals Covered	57
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,170
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	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $27,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,170
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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

Policy contract number

000003666

Policy instance

Insurance contract or identification number	000003666
Number of Individuals Covered	141
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,220
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 $53,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,607
Insurance broker organization code?	3
Insurance broker name	COMBINED SERVICES LLC

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

Policy contract number

055438

Policy instance

Insurance contract or identification number	055438
Number of Individuals Covered	45
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $8,728
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $320,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,728
Insurance broker organization code?	3
Insurance broker name	LANDMARK BENEFITS INC

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Company Name:	LACONIA CLINIC
Employer identification number (EIN):	020460192
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)