401k Plan data: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN plan

SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 401k Plan overview

Plan Name	SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN
Plan identification number	501

SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Long-term disability cover

401k Sponsoring company profile

SOUTH SHORE MEDICAL CENTER, INC. has sponsored the creation of one or more 401k plans.

Company Name: SOUTH SHORE MEDICAL CENTER, INC.

Employer identification number (EIN): 042297845

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

Additional information about SOUTH SHORE MEDICAL CENTER, INC.

Jurisdiction of Incorporation: Florida Department of State Division of Corporations

Incorporation Date: 2002-03-22

Company Identification Number: P02000034238

Legal Registered Office Address: 3040 STATE ROAD 674

RUSKIN

33570

More information about SOUTH SHORE MEDICAL CENTER, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-01-01 MICHAEL KAPLAN MICHAEL KAPLAN 2017-10-10
501 2016-01-01 WAYNE STOCKBRIDGE WAYNE STOCKBRIDGE 2018-09-14
501 2015-01-01 MICHAEL KAPLAN MICHAEL KAPLAN 2016-07-12
501 2014-01-01 MIKE KAPLAN MIKE KAPLAN 2015-06-12
501 2013-01-01 MIKE KAPLAN MIKE KAPLAN 2014-05-14
501 2012-01-01 MIKE KAPLAN MIKE KAPLAN 2013-07-26
501 2011-01-01 THOMAS E. CARROLL JR. THOMAS E. CARROLL JR. 2012-06-11
501 2009-01-01 THOMAS E. CARROLL JR. THOMAS E. CARROLL JR. 2012-02-28
501 2008-01-01 THOMAS E. CARROLL JR. THOMAS E. CARROLL JR. 2012-02-28
501 2007-01-01 THOMAS E. CARROLL JR. THOMAS E. CARROLL JR. 2012-02-28
501 2005-01-01 THOMAS E. CARROLL JR. THOMAS E. CARROLL JR. 2012-02-28

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2016-01-01	MICHAEL KAPLAN	MICHAEL KAPLAN	2017-10-10
501	2016-01-01	WAYNE STOCKBRIDGE	WAYNE STOCKBRIDGE	2018-09-14
501	2015-01-01	MICHAEL KAPLAN	MICHAEL KAPLAN	2016-07-12
501	2014-01-01	MIKE KAPLAN	MIKE KAPLAN	2015-06-12
501	2013-01-01	MIKE KAPLAN	MIKE KAPLAN	2014-05-14
501	2012-01-01	MIKE KAPLAN	MIKE KAPLAN	2013-07-26
501	2011-01-01	THOMAS E. CARROLL JR.	THOMAS E. CARROLL JR.	2012-06-11
501	2009-01-01	THOMAS E. CARROLL JR.	THOMAS E. CARROLL JR.	2012-02-28
501	2008-01-01	THOMAS E. CARROLL JR.	THOMAS E. CARROLL JR.	2012-02-28
501	2007-01-01	THOMAS E. CARROLL JR.	THOMAS E. CARROLL JR.	2012-02-28
501	2005-01-01	THOMAS E. CARROLL JR.	THOMAS E. CARROLL JR.	2012-02-28

Plan Statistics for SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN

401k plan membership statisitcs for SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN

Measure Date Value
2016: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 278
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 272
Total of all active and inactive participants 2016-01-01 272
Total participants 2016-01-01 0
2015: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 294
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 278
Total of all active and inactive participants 2015-01-01 278
2014: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 303
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 294
Total of all active and inactive participants 2014-01-01 294
2013: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 300
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 303
Total of all active and inactive participants 2013-01-01 303
2012: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 289
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 300
Total of all active and inactive participants 2012-01-01 300
2011: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 645
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 680
Total of all active and inactive participants 2011-01-01 680
2009: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 491
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 569
Total of all active and inactive participants 2009-01-01 569
2008: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2008 401k membership
Total participants, beginning-of-year 2008-01-01 443
Total number of active participants reported on line 7a of the Form 5500 2008-01-01 491
Total of all active and inactive participants 2008-01-01 491
2007: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2007 401k membership
Total participants, beginning-of-year 2007-01-01 446
Total number of active participants reported on line 7a of the Form 5500 2007-01-01 443
Total of all active and inactive participants 2007-01-01 443
2005: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2005 401k membership
Total participants, beginning-of-year 2005-01-01 247
Total number of active participants reported on line 7a of the Form 5500 2005-01-01 411
Total of all active and inactive participants 2005-01-01 411

Measure	Date	Value
2016: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	278
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	272
Total of all active and inactive participants	2016-01-01	272
Total participants	2016-01-01	0
2015: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	294
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	278
Total of all active and inactive participants	2015-01-01	278
2014: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	303
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	294
Total of all active and inactive participants	2014-01-01	294
2013: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	300
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	303
Total of all active and inactive participants	2013-01-01	303
2012: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	289
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	300
Total of all active and inactive participants	2012-01-01	300
2011: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	645
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	680
Total of all active and inactive participants	2011-01-01	680
2009: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	491
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	569
Total of all active and inactive participants	2009-01-01	569
2008: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2008 401k membership
Total participants, beginning-of-year	2008-01-01	443
Total number of active participants reported on line 7a of the Form 5500	2008-01-01	491
Total of all active and inactive participants	2008-01-01	491
2007: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2007 401k membership
Total participants, beginning-of-year	2007-01-01	446
Total number of active participants reported on line 7a of the Form 5500	2007-01-01	443
Total of all active and inactive participants	2007-01-01	443
2005: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2005 401k membership
Total participants, beginning-of-year	2005-01-01	247
Total number of active participants reported on line 7a of the Form 5500	2005-01-01	411
Total of all active and inactive participants	2005-01-01	411

Form 5500 Responses for SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN

2016: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	Yes
2016-01-01	This submission is the final filing	Yes
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL 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 benefit arrangement – Insurance	Yes
2014: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL 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 benefit arrangement – Insurance	Yes
2013: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL 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 benefit arrangement – Insurance	Yes
2011: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL 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 benefit arrangement – Insurance	Yes
2009: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL 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 benefit arrangement – Insurance	Yes
2008: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2008 form 5500 responses
2008-01-01	Type of plan entity	Single employer plan
2008-01-01	Plan funding arrangement – Insurance	Yes
2008-01-01	Plan benefit arrangement – Insurance	Yes
2007: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2007 form 5500 responses
2007-01-01	Type of plan entity	Single employer plan
2007-01-01	Plan funding arrangement – Insurance	Yes
2007-01-01	Plan benefit arrangement – Insurance	Yes
2005: SOUTH SHORE MEDICAL CENTER EMPLOYEE MEDICAL PLAN 2005 form 5500 responses
2005-01-01	Type of plan entity	Single employer plan
2005-01-01	Plan funding arrangement – Insurance	Yes
2005-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

561724

Policy instance

Insurance contract or identification number	561724
Number of Individuals Covered	446
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $13,136
Total amount of fees paid to insurance company	USD $372
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $87,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,670
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4957922

Policy instance

Insurance contract or identification number	4957922
Number of Individuals Covered	616
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $225,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BLUE CROSS BLUE SHIELD OF MA

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

Policy contract number

313761

Policy instance

Insurance contract or identification number	313761
Number of Individuals Covered	120
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $62,694
Total amount of fees paid to insurance company	USD $1,776
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $454,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,378
Insurance broker organization code?	3
Amount paid for insurance broker fees	1776
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4957010

Policy instance

Insurance contract or identification number	4957010
Number of Individuals Covered	665
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $133,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BLUE CROSS BLUE SHIELD OF MA

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

Policy contract number

313761

Policy instance

Insurance contract or identification number	313761
Number of Individuals Covered	114
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $63,717
Total amount of fees paid to insurance company	USD $1,805
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 $424,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,053
Insurance broker organization code?	3
Amount paid for insurance broker fees	750
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )

Policy contract number

000458

Policy instance

Insurance contract or identification number	000458
Number of Individuals Covered	638
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $19,159
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 $241,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	19159
Insurance broker organization code?	3
Insurance broker name	DELTA DENTAL OF MASSACHUSETTS

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

Policy contract number

561724

Policy instance

Insurance contract or identification number	561724
Number of Individuals Covered	443
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $13,685
Total amount of fees paid to insurance company	USD $388
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
Welfare Benefit Premiums Paid to Carrier	USD $91,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,032
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4957010

Policy instance

Insurance contract or identification number	4957010
Number of Individuals Covered	692
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $132,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BLUE CROSS BLUE SHIELD OF MA

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

Policy contract number

313761

Policy instance

Insurance contract or identification number	313761
Number of Individuals Covered	109
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $58,975
Total amount of fees paid to insurance company	USD $1,671
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 $393,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,923
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LONGFELLOW FINANCIAL LLC INSURANCE

DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )

Policy contract number

000458

Policy instance

Insurance contract or identification number	000458
Number of Individuals Covered	644
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $19,170
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 $217,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	19170
Insurance broker organization code?	3
Insurance broker name	DELTA DENTAL OF MASSACHUSETTS

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

Policy contract number

561724

Policy instance

Insurance contract or identification number	561724
Number of Individuals Covered	449
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $14,772
Total amount of fees paid to insurance company	USD $398
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
Welfare Benefit Premiums Paid to Carrier	USD $93,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,998
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LONGFELLOW FINANCIAL LLC INSURANCE

DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )

Policy contract number

000458

Policy instance

Insurance contract or identification number	000458
Number of Individuals Covered	592
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $18,091
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 $214,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	18091
Insurance broker organization code?	3
Insurance broker name	DELTA DENTAL OF MASSACHUSETTS

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

Policy contract number

313761

Policy instance

Insurance contract or identification number	313761
Number of Individuals Covered	103
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $40,491
Total amount of fees paid to insurance company	USD $1,147
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 $269,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,724
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LONGFELLOW FINANCIAL LLC INSURANCE

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

Policy contract number

561724

Policy instance

Insurance contract or identification number	561724
Number of Individuals Covered	441
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $12,392
Total amount of fees paid to insurance company	USD $372
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
Welfare Benefit Premiums Paid to Carrier	USD $87,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,930
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LONGFELLOW FINANCIAL LLC INSURANCE

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4957010

Policy instance

Insurance contract or identification number	4957010
Number of Individuals Covered	683
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $126,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BLUE CROSS BLUE SHIELD OF MA

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

Policy contract number

053096

Policy instance

Insurance contract or identification number	053096
Number of Individuals Covered	41
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,776
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

561724

Policy instance

Insurance contract or identification number	561724
Number of Individuals Covered	414
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $12,365
Total amount of fees paid to insurance company	USD $350
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
Welfare Benefit Premiums Paid to Carrier	USD $82,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )

Policy contract number

000458

Policy instance

Insurance contract or identification number	000458
Number of Individuals Covered	527
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $16,189
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 $192,639
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

065826

Policy instance

Insurance contract or identification number	065826
Number of Individuals Covered	628
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $167,615
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

065827

Policy instance

Insurance contract or identification number	065827
Number of Individuals Covered	11
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	POS POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $1,871
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

313761

Policy instance

Insurance contract or identification number	313761
Number of Individuals Covered	99
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $39,098
Total amount of fees paid to insurance company	USD $1,108
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
Welfare Benefit Premiums Paid to Carrier	USD $260,654
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

313761

Policy instance

Insurance contract or identification number	313761
Number of Individuals Covered	89
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $37,476
Total amount of fees paid to insurance company	USD $1,062
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
Welfare Benefit Premiums Paid to Carrier	USD $230,582
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

065827

Policy instance

Insurance contract or identification number	065827
Number of Individuals Covered	9
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	POS POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $2,150
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

065826

Policy instance

Insurance contract or identification number	065826
Number of Individuals Covered	606
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $167,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )

Policy contract number

000458

Policy instance

Insurance contract or identification number	000458
Number of Individuals Covered	474
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $14,663
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 $176,012
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

561724

Policy instance

Insurance contract or identification number	561724
Number of Individuals Covered	400
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $11,480
Total amount of fees paid to insurance company	USD $339
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
Welfare Benefit Premiums Paid to Carrier	USD $73,246
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

053096

Policy instance

Insurance contract or identification number	053096
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 $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

010-30010

Policy instance

Insurance contract or identification number	010-30010
Number of Individuals Covered	279
Insurance policy start date	2008-01-01
Insurance policy end date	2008-01-01
Total amount of commissions paid to insurance broker	USD $4,305
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 $81,107
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

053096

Policy instance

Insurance contract or identification number	053096
Number of Individuals Covered	18
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,656
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

313761

Policy instance

Insurance contract or identification number	313761
Number of Individuals Covered	91
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $5,957
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
Welfare Benefit Premiums Paid to Carrier	USD $195,693
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

065826

Policy instance

Insurance contract or identification number	065826
Number of Individuals Covered	456
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $111,047
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

065827

Policy instance

Insurance contract or identification number	065827
Number of Individuals Covered	17
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	POS POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $3,684
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

561724

Policy instance

Insurance contract or identification number	561724
Number of Individuals Covered	429
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $4,328
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
Welfare Benefit Premiums Paid to Carrier	USD $63,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

010-30010

Policy instance

Insurance contract or identification number	010-30010
Number of Individuals Covered	231
Insurance policy start date	2007-01-01
Insurance policy end date	2007-12-31
Total amount of commissions paid to insurance broker	USD $3,633
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 $72,665
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

561724

Policy instance

Insurance contract or identification number	561724
Number of Individuals Covered	429
Insurance policy start date	2007-01-01
Insurance policy end date	2007-12-31
Total amount of commissions paid to insurance broker	USD $4,198
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
Welfare Benefit Premiums Paid to Carrier	USD $56,905
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

065827

Policy instance

Insurance contract or identification number	065827
Number of Individuals Covered	17
Insurance policy start date	2007-01-01
Insurance policy end date	2007-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	POS POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $3,229
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

065826

Policy instance

Insurance contract or identification number	065826
Number of Individuals Covered	426
Insurance policy start date	2007-01-01
Insurance policy end date	2007-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,835
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

313761

Policy instance

Insurance contract or identification number	313761
Number of Individuals Covered	91
Insurance policy start date	2007-01-01
Insurance policy end date	2007-12-31
Total amount of commissions paid to insurance broker	USD $5,559
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
Welfare Benefit Premiums Paid to Carrier	USD $155,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

607531

Policy instance

Insurance contract or identification number	607531
Number of Individuals Covered	35
Insurance policy start date	2006-01-01
Insurance policy end date	2006-12-31
Total amount of commissions paid to insurance broker	USD $1,079
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 $21,577
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

561724

Policy instance

Insurance contract or identification number	561724
Number of Individuals Covered	429
Insurance policy start date	2006-01-01
Insurance policy end date	2006-12-31
Total amount of commissions paid to insurance broker	USD $3,988
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
Welfare Benefit Premiums Paid to Carrier	USD $52,929
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

065827

Policy instance

Insurance contract or identification number	065827
Number of Individuals Covered	22
Insurance policy start date	2006-01-01
Insurance policy end date	2006-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	POS POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $7,006
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

065826

Policy instance

Insurance contract or identification number	065826
Number of Individuals Covered	424
Insurance policy start date	2006-01-01
Insurance policy end date	2006-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $135,589
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

313761

Policy instance

Insurance contract or identification number	313761
Number of Individuals Covered	92
Insurance policy start date	2006-01-01
Insurance policy end date	2006-12-31
Total amount of commissions paid to insurance broker	USD $5,442
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
Welfare Benefit Premiums Paid to Carrier	USD $144,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

607532

Policy instance

Insurance contract or identification number	607532
Number of Individuals Covered	48
Insurance policy start date	2006-01-01
Insurance policy end date	2006-12-31
Total amount of commissions paid to insurance broker	USD $2,225
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 $44,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

607531

Policy instance

Insurance contract or identification number	607531
Number of Individuals Covered	38
Insurance policy start date	2005-01-01
Insurance policy end date	2005-12-31
Total amount of commissions paid to insurance broker	USD $1,051
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 $21,020
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

62235

Policy instance

Insurance contract or identification number	62235
Number of Individuals Covered	429
Insurance policy start date	2005-01-01
Insurance policy end date	2005-12-31
Total amount of commissions paid to insurance broker	USD $3,787
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
Welfare Benefit Premiums Paid to Carrier	USD $49,857
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

065827

Policy instance

Insurance contract or identification number	065827
Number of Individuals Covered	21
Insurance policy start date	2005-01-01
Insurance policy end date	2005-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	POS POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $6,914
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

065826

Policy instance

Insurance contract or identification number	065826
Number of Individuals Covered	390
Insurance policy start date	2005-01-01
Insurance policy end date	2005-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $120,696
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

313761

Policy instance

Insurance contract or identification number	313761
Number of Individuals Covered	91
Insurance policy start date	2005-01-01
Insurance policy end date	2005-12-31
Total amount of commissions paid to insurance broker	USD $5,578
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
Welfare Benefit Premiums Paid to Carrier	USD $146,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

607532

Policy instance

Insurance contract or identification number	607532
Number of Individuals Covered	56
Insurance policy start date	2005-01-01
Insurance policy end date	2005-12-31
Total amount of commissions paid to insurance broker	USD $2,222
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 $44,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SOUTH SHORE MEDICAL CENTER, INC.
Employer identification number (EIN):	042297845
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)

Jurisdiction of Incorporation:	Florida Department of State Division of Corporations
Incorporation Date:	2002-03-22
Company Identification Number:	P02000034238
Legal Registered Office Address:	3040 STATE ROAD 674 RUSKIN 33570