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SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan NameSHERRILL HOUSE EMPLOYEE BENEFITS PLAN
Plan identification number 501

SHERRILL HOUSE EMPLOYEE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Prepaid legal
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

SHERRILL HOUSE has sponsored the creation of one or more 401k plans.

Company Name:SHERRILL HOUSE
Employer identification number (EIN):042104321
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SHERRILL HOUSE EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-06-01
5012021-06-01
5012020-06-01
5012019-06-01
5012018-06-01
5012017-06-01MARC SCHULTZ
5012016-06-01DONALD GREGORY
5012015-06-01DONALD GREGORY
5012014-06-01DONALD GREGORY DONALD GREGORY2015-12-09
5012013-06-01DONALD GREGORY
5012012-06-01DONALD GREGORY
5012011-06-01DONALD GREGORY DONALD GREGORY2012-12-12
5012010-06-01DONALD GREGORY DONALD GREGORY2011-12-15
5012009-06-01DONALD GREGORY

Plan Statistics for SHERRILL HOUSE EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for SHERRILL HOUSE EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-06-01138
Total number of active participants reported on line 7a of the Form 55002022-06-01157
Number of retired or separated participants receiving benefits2022-06-013
Total of all active and inactive participants2022-06-01160
2021: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-06-01182
Total number of active participants reported on line 7a of the Form 55002021-06-01138
Number of retired or separated participants receiving benefits2021-06-010
Number of other retired or separated participants entitled to future benefits2021-06-010
Total of all active and inactive participants2021-06-01138
2020: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-06-01194
Total number of active participants reported on line 7a of the Form 55002020-06-01182
Number of retired or separated participants receiving benefits2020-06-010
Number of other retired or separated participants entitled to future benefits2020-06-010
Total of all active and inactive participants2020-06-01182
2019: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-06-01191
Total number of active participants reported on line 7a of the Form 55002019-06-01190
Number of retired or separated participants receiving benefits2019-06-014
Number of other retired or separated participants entitled to future benefits2019-06-010
Total of all active and inactive participants2019-06-01194
2018: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-06-01168
Total number of active participants reported on line 7a of the Form 55002018-06-01191
Number of retired or separated participants receiving benefits2018-06-010
Number of other retired or separated participants entitled to future benefits2018-06-010
Total of all active and inactive participants2018-06-01191
2017: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-06-01181
Total number of active participants reported on line 7a of the Form 55002017-06-01168
Number of retired or separated participants receiving benefits2017-06-010
Number of other retired or separated participants entitled to future benefits2017-06-010
Total of all active and inactive participants2017-06-01168
2016: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-06-01187
Total number of active participants reported on line 7a of the Form 55002016-06-01181
Number of retired or separated participants receiving benefits2016-06-010
Number of other retired or separated participants entitled to future benefits2016-06-010
Total of all active and inactive participants2016-06-01181
2015: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-06-01188
Total number of active participants reported on line 7a of the Form 55002015-06-01187
Number of retired or separated participants receiving benefits2015-06-010
Number of other retired or separated participants entitled to future benefits2015-06-010
Total of all active and inactive participants2015-06-01187
2014: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-06-01194
Total number of active participants reported on line 7a of the Form 55002014-06-01188
Number of retired or separated participants receiving benefits2014-06-010
Number of other retired or separated participants entitled to future benefits2014-06-010
Total of all active and inactive participants2014-06-01188
2013: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-06-01216
Total number of active participants reported on line 7a of the Form 55002013-06-01194
Number of retired or separated participants receiving benefits2013-06-010
Number of other retired or separated participants entitled to future benefits2013-06-010
Total of all active and inactive participants2013-06-01194
2012: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-06-01197
Total number of active participants reported on line 7a of the Form 55002012-06-01216
Number of retired or separated participants receiving benefits2012-06-010
Total of all active and inactive participants2012-06-01216
2011: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-06-01207
Total number of active participants reported on line 7a of the Form 55002011-06-01197
Total of all active and inactive participants2011-06-01197
2010: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-06-01190
Total number of active participants reported on line 7a of the Form 55002010-06-01207
Total of all active and inactive participants2010-06-01207
2009: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-06-01207
Total number of active participants reported on line 7a of the Form 55002009-06-01187
Number of retired or separated participants receiving benefits2009-06-013
Total of all active and inactive participants2009-06-01190

Form 5500 Responses for SHERRILL HOUSE EMPLOYEE BENEFITS PLAN

2022: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-06-01Type of plan entitySingle employer plan
2022-06-01Submission has been amendedNo
2022-06-01This submission is the final filingNo
2022-06-01This return/report is a short plan year return/report (less than 12 months)No
2022-06-01Plan is a collectively bargained planNo
2022-06-01Plan funding arrangement – InsuranceYes
2022-06-01Plan funding arrangement – General assets of the sponsorYes
2022-06-01Plan benefit arrangement – InsuranceYes
2022-06-01Plan benefit arrangement – General assets of the sponsorYes
2021: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-06-01Type of plan entitySingle employer plan
2021-06-01Submission has been amendedNo
2021-06-01This submission is the final filingNo
2021-06-01This return/report is a short plan year return/report (less than 12 months)No
2021-06-01Plan is a collectively bargained planNo
2021-06-01Plan funding arrangement – InsuranceYes
2021-06-01Plan funding arrangement – General assets of the sponsorYes
2021-06-01Plan benefit arrangement – InsuranceYes
2021-06-01Plan benefit arrangement – General assets of the sponsorYes
2020: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-06-01Type of plan entitySingle employer plan
2020-06-01Submission has been amendedNo
2020-06-01This submission is the final filingNo
2020-06-01This return/report is a short plan year return/report (less than 12 months)No
2020-06-01Plan is a collectively bargained planNo
2020-06-01Plan funding arrangement – InsuranceYes
2020-06-01Plan funding arrangement – General assets of the sponsorYes
2020-06-01Plan benefit arrangement – InsuranceYes
2020-06-01Plan benefit arrangement – General assets of the sponsorYes
2019: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-06-01Type of plan entitySingle employer plan
2019-06-01Submission has been amendedNo
2019-06-01This submission is the final filingNo
2019-06-01This return/report is a short plan year return/report (less than 12 months)No
2019-06-01Plan is a collectively bargained planNo
2019-06-01Plan funding arrangement – InsuranceYes
2019-06-01Plan funding arrangement – General assets of the sponsorYes
2019-06-01Plan benefit arrangement – InsuranceYes
2019-06-01Plan benefit arrangement – General assets of the sponsorYes
2018: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-06-01Type of plan entitySingle employer plan
2018-06-01Submission has been amendedNo
2018-06-01This submission is the final filingNo
2018-06-01This return/report is a short plan year return/report (less than 12 months)No
2018-06-01Plan is a collectively bargained planNo
2018-06-01Plan funding arrangement – InsuranceYes
2018-06-01Plan funding arrangement – General assets of the sponsorYes
2018-06-01Plan benefit arrangement – InsuranceYes
2018-06-01Plan benefit arrangement – General assets of the sponsorYes
2017: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-06-01Type of plan entitySingle employer plan
2017-06-01Submission has been amendedNo
2017-06-01This submission is the final filingNo
2017-06-01This return/report is a short plan year return/report (less than 12 months)No
2017-06-01Plan is a collectively bargained planNo
2017-06-01Plan funding arrangement – InsuranceYes
2017-06-01Plan funding arrangement – General assets of the sponsorYes
2017-06-01Plan benefit arrangement – InsuranceYes
2017-06-01Plan benefit arrangement – General assets of the sponsorYes
2016: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-06-01Type of plan entitySingle employer plan
2016-06-01Submission has been amendedNo
2016-06-01This submission is the final filingNo
2016-06-01This return/report is a short plan year return/report (less than 12 months)No
2016-06-01Plan is a collectively bargained planNo
2016-06-01Plan funding arrangement – InsuranceYes
2016-06-01Plan funding arrangement – General assets of the sponsorYes
2016-06-01Plan benefit arrangement – InsuranceYes
2016-06-01Plan benefit arrangement – General assets of the sponsorYes
2015: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01Submission has been amendedNo
2015-06-01This submission is the final filingNo
2015-06-01This return/report is a short plan year return/report (less than 12 months)No
2015-06-01Plan is a collectively bargained planNo
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan funding arrangement – General assets of the sponsorYes
2015-06-01Plan benefit arrangement – InsuranceYes
2015-06-01Plan benefit arrangement – General assets of the sponsorYes
2014: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-06-01Type of plan entitySingle employer plan
2014-06-01Submission has been amendedNo
2014-06-01This submission is the final filingNo
2014-06-01This return/report is a short plan year return/report (less than 12 months)No
2014-06-01Plan is a collectively bargained planNo
2014-06-01Plan funding arrangement – InsuranceYes
2014-06-01Plan benefit arrangement – InsuranceYes
2013: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2013 form 5500 responses
2013-06-01Type of plan entitySingle employer plan
2013-06-01Submission has been amendedNo
2013-06-01This submission is the final filingNo
2013-06-01This return/report is a short plan year return/report (less than 12 months)No
2013-06-01Plan is a collectively bargained planNo
2013-06-01Plan funding arrangement – InsuranceYes
2013-06-01Plan benefit arrangement – InsuranceYes
2012: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2012 form 5500 responses
2012-06-01Type of plan entitySingle employer plan
2012-06-01Submission has been amendedYes
2012-06-01This submission is the final filingNo
2012-06-01This return/report is a short plan year return/report (less than 12 months)No
2012-06-01Plan is a collectively bargained planNo
2012-06-01Plan funding arrangement – InsuranceYes
2012-06-01Plan benefit arrangement – InsuranceYes
2011: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2011 form 5500 responses
2011-06-01Type of plan entitySingle employer plan
2011-06-01Submission has been amendedNo
2011-06-01This submission is the final filingNo
2011-06-01This return/report is a short plan year return/report (less than 12 months)No
2011-06-01Plan is a collectively bargained planNo
2011-06-01Plan funding arrangement – InsuranceYes
2011-06-01Plan benefit arrangement – InsuranceYes
2010: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2010 form 5500 responses
2010-06-01Type of plan entitySingle employer plan
2010-06-01Submission has been amendedNo
2010-06-01This submission is the final filingNo
2010-06-01This return/report is a short plan year return/report (less than 12 months)No
2010-06-01Plan is a collectively bargained planNo
2010-06-01Plan funding arrangement – InsuranceYes
2010-06-01Plan benefit arrangement – InsuranceYes
2009: SHERRILL HOUSE EMPLOYEE BENEFITS PLAN 2009 form 5500 responses
2009-06-01Type of plan entitySingle employer plan
2009-06-01Submission has been amendedNo
2009-06-01This submission is the final filingNo
2009-06-01This return/report is a short plan year return/report (less than 12 months)No
2009-06-01Plan is a collectively bargained planNo
2009-06-01Plan funding arrangement – InsuranceYes
2009-06-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97211191001
Policy instance 6
Insurance contract or identification number97211191001
Number of Individuals Covered136
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $798
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $9,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $798
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 127315
Policy instance 5
Insurance contract or identification numberLTD 127315
Number of Individuals Covered157
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $4,146
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $41,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,146
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 155611
Policy instance 4
Insurance contract or identification numberGL 155611
Number of Individuals Covered157
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $2,329
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 CarrierUSD $30,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,329
Insurance broker organization code?3
METROPOLITAN GENERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 39950 )
Policy contract number8210010
Policy instance 3
Insurance contract or identification number8210010
Number of Individuals Covered3
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $79
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedPRE-PAID LEGAL
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 CarrierUSD $790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $79
Insurance broker organization code?3
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number103621, 103622
Policy instance 2
Insurance contract or identification number103621, 103622
Number of Individuals Covered163
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $29,566
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,349,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,566
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4957777
Policy instance 1
Insurance contract or identification number4957777
Number of Individuals Covered202
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $4,419
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,419
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4957777
Policy instance 1
Insurance contract or identification number4957777
Number of Individuals Covered182
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $4,336
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,336
Insurance broker organization code?3
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number103621, 103622
Policy instance 2
Insurance contract or identification number103621, 103622
Number of Individuals Covered171
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $29,928
Total amount of fees paid to insurance companyUSD $7,823
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,115,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,928
Amount paid for insurance broker fees7823
Additional information about fees paid to insurance brokerBONUS NOT APPLIED TO ACCOUNT
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 155611
Policy instance 3
Insurance contract or identification numberGL 155611
Number of Individuals Covered138
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $2,051
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 CarrierUSD $23,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,051
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 127315
Policy instance 4
Insurance contract or identification numberLTD 127315
Number of Individuals Covered137
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $3,835
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $32,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,835
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97211191001
Policy instance 5
Insurance contract or identification number97211191001
Number of Individuals Covered127
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $928
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $8,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $928
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97211191001
Policy instance 5
Insurance contract or identification number97211191001
Number of Individuals Covered147
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $932
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $8,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $932
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 127315
Policy instance 4
Insurance contract or identification numberLTD 127315
Number of Individuals Covered181
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $3,729
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $34,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,729
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 155611
Policy instance 3
Insurance contract or identification numberGL 155611
Number of Individuals Covered182
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $2,059
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 CarrierUSD $26,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,059
Insurance broker organization code?3
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number103621, 103622
Policy instance 2
Insurance contract or identification number103621, 103622
Number of Individuals Covered177
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $30,809
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,056,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,809
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4957777
Policy instance 1
Insurance contract or identification number4957777
Number of Individuals Covered198
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $4,335
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?Yes
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,335
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 155611
Policy instance 3
Insurance contract or identification numberGL 155611
Number of Individuals Covered190
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $2,437
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 CarrierUSD $34,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,437
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4957777
Policy instance 1
Insurance contract or identification number4957777
Number of Individuals Covered228
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $4,658
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,658
Insurance broker organization code?3
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number103621, 103622
Policy instance 2
Insurance contract or identification number103621, 103622
Number of Individuals Covered198
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $21,694
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,204,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,694
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 127315
Policy instance 4
Insurance contract or identification numberLTD 127315
Number of Individuals Covered190
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $4,267
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $45,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,267
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97211191001
Policy instance 5
Insurance contract or identification number97211191001
Number of Individuals Covered167
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $984
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $12,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $984
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97211191001
Policy instance 5
Insurance contract or identification number97211191001
Number of Individuals Covered174
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $1,068
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $8,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,068
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4957777
Policy instance 1
Insurance contract or identification number4957777
Number of Individuals Covered239
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $4,283
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,283
Insurance broker organization code?3
NEIGHBORHOOD HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 11109 )
Policy contract number5CB / ARAC10080
Policy instance 2
Insurance contract or identification number5CB / ARAC10080
Number of Individuals Covered113
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $32,463
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,179,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,463
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 155611
Policy instance 3
Insurance contract or identification numberGL 155611
Number of Individuals Covered191
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $2,139
Total amount of fees paid to insurance companyUSD $174
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 CarrierUSD $27,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,139
Amount paid for insurance broker fees174
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 127315
Policy instance 4
Insurance contract or identification numberLTD 127315
Number of Individuals Covered191
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $3,846
Total amount of fees paid to insurance companyUSD $255
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $36,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,846
Amount paid for insurance broker fees255
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97211191001
Policy instance 5
Insurance contract or identification number97211191001
Number of Individuals Covered176
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $927
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $11,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $927
Insurance broker organization code?3
Insurance broker nameEBS INSURANCE BROKERS
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 127315
Policy instance 4
Insurance contract or identification numberLTD 127315
Number of Individuals Covered168
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $4,126
Total amount of fees paid to insurance companyUSD $1,376
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $42,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,126
Amount paid for insurance broker fees1376
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?3
Insurance broker nameEBS INSURANCE BROKERS, INC.
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 155611
Policy instance 3
Insurance contract or identification numberGL 155611
Number of Individuals Covered168
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $2,208
Total amount of fees paid to insurance companyUSD $940
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 CarrierUSD $28,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,208
Amount paid for insurance broker fees940
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?3
Insurance broker nameEBS INSURANCE BROKERS, INC.
NEIGHBORHOOD HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 11109 )
Policy contract number5CB / ARAC10080
Policy instance 2
Insurance contract or identification number5CB / ARAC10080
Number of Individuals Covered117
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $40,958
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,009,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,958
Insurance broker organization code?3
Insurance broker nameEBS INSURANCE BROKERS
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4957777
Policy instance 1
Insurance contract or identification number4957777
Number of Individuals Covered261
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $4,973
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,973
Insurance broker organization code?3
Insurance broker nameEBS INSURANCE BROKERS

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