401k Plan data: SULLIVAN TIRE CO., INC GR MEDICAL PLAN plan

SULLIVAN TIRE CO., INC GR MEDICAL PLAN 401k Plan overview

Plan Name	SULLIVAN TIRE CO., INC GR MEDICAL PLAN
Plan identification number	501

SULLIVAN TIRE CO., INC GR MEDICAL PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

SULLIVAN INVESTMENT CO., INC. has sponsored the creation of one or more 401k plans.

Company Name: SULLIVAN INVESTMENT CO., INC.

Employer identification number (EIN): 042682840

NAIC Classification: 441300
NAIC Description: Automotive Parts, Accessories, and Tire Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SULLIVAN TIRE CO., INC GR MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 JOSEPH ZACCHEO 2023-06-29
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 ROBERT D. SULLIVAN ROBERT D. SULLIVAN 2018-07-30
501 2016-01-01 ROBERT D. SULLIVAN ROBERT D. SULLIVAN 2017-07-13
501 2015-01-01 ROBERT D. SULLIVAN ROBERT D. SULLIVAN 2016-07-27
501 2014-01-01 ROBERT D. SULLIVAN ROBERT D. SULLIVAN 2015-07-30
501 2013-01-01 ROBERT D. SULLIVAN ROBERT D. SULLIVAN 2014-07-30
501 2012-01-01 ROBERT D. SULLIVAN ROBERT D. SULLIVAN 2013-07-30
501 2011-01-01 ROBERT D. SULLIVAN ROBERT D. SULLIVAN 2012-07-24
501 2010-01-01 ROBERT D. SULLIVAN ROBERT D. SULLIVAN 2011-07-27

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	JOSEPH ZACCHEO	2023-06-29
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	ROBERT D. SULLIVAN		ROBERT D. SULLIVAN	2018-07-30
501	2016-01-01	ROBERT D. SULLIVAN		ROBERT D. SULLIVAN	2017-07-13
501	2015-01-01	ROBERT D. SULLIVAN		ROBERT D. SULLIVAN	2016-07-27
501	2014-01-01	ROBERT D. SULLIVAN		ROBERT D. SULLIVAN	2015-07-30
501	2013-01-01	ROBERT D. SULLIVAN		ROBERT D. SULLIVAN	2014-07-30
501	2012-01-01	ROBERT D. SULLIVAN		ROBERT D. SULLIVAN	2013-07-30
501	2011-01-01	ROBERT D. SULLIVAN		ROBERT D. SULLIVAN	2012-07-24
501	2010-01-01	ROBERT D. SULLIVAN		ROBERT D. SULLIVAN	2011-07-27

Plan Statistics for SULLIVAN TIRE CO., INC GR MEDICAL PLAN

401k plan membership statisitcs for SULLIVAN TIRE CO., INC GR MEDICAL PLAN

Measure Date Value
2022: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 1,134
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 1,142
Number of retired or separated participants receiving benefits 2022-01-01 3
Number of other retired or separated participants entitled to future benefits 2022-01-01 71
Total of all active and inactive participants 2022-01-01 1,216
2021: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 1,082
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 1,134
Total of all active and inactive participants 2021-01-01 1,134
Total participants 2021-01-01 1,134
2020: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 1,176
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 1,082
Total of all active and inactive participants 2020-01-01 1,082
Total participants 2020-01-01 1,082
2019: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,120
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 1,176
Total of all active and inactive participants 2019-01-01 1,176
Total participants 2019-01-01 1,176
2018: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 1,106
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 1,120
Total of all active and inactive participants 2018-01-01 1,120
Total participants 2018-01-01 1,120
2017: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 1,081
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 1,106
Total of all active and inactive participants 2017-01-01 1,106
Total participants 2017-01-01 1,106
2016: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,066
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 1,081
Total of all active and inactive participants 2016-01-01 1,081
Total participants 2016-01-01 1,081
2015: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,018
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,066
Total of all active and inactive participants 2015-01-01 1,066
Total participants 2015-01-01 1,066
2014: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,001
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,018
Total of all active and inactive participants 2014-01-01 1,018
Total participants 2014-01-01 1,018
2013: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 972
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,001
Total of all active and inactive participants 2013-01-01 1,001
Total participants 2013-01-01 1,001
2012: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 897
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 972
Total of all active and inactive participants 2012-01-01 972
Total participants 2012-01-01 972
2011: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 809
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 897
Total of all active and inactive participants 2011-01-01 897
Total participants 2011-01-01 897
2010: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 782
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 809
Total of all active and inactive participants 2010-01-01 809
Total participants 2010-01-01 809

Measure	Date	Value
2022: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	1,134
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	1,142
Number of retired or separated participants receiving benefits	2022-01-01	3
Number of other retired or separated participants entitled to future benefits	2022-01-01	71
Total of all active and inactive participants	2022-01-01	1,216
2021: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	1,082
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	1,134
Total of all active and inactive participants	2021-01-01	1,134
Total participants	2021-01-01	1,134
2020: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	1,176
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,082
Total of all active and inactive participants	2020-01-01	1,082
Total participants	2020-01-01	1,082
2019: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,120
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	1,176
Total of all active and inactive participants	2019-01-01	1,176
Total participants	2019-01-01	1,176
2018: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	1,106
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,120
Total of all active and inactive participants	2018-01-01	1,120
Total participants	2018-01-01	1,120
2017: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,081
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,106
Total of all active and inactive participants	2017-01-01	1,106
Total participants	2017-01-01	1,106
2016: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,066
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,081
Total of all active and inactive participants	2016-01-01	1,081
Total participants	2016-01-01	1,081
2015: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,018
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,066
Total of all active and inactive participants	2015-01-01	1,066
Total participants	2015-01-01	1,066
2014: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,001
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,018
Total of all active and inactive participants	2014-01-01	1,018
Total participants	2014-01-01	1,018
2013: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	972
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,001
Total of all active and inactive participants	2013-01-01	1,001
Total participants	2013-01-01	1,001
2012: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	897
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	972
Total of all active and inactive participants	2012-01-01	972
Total participants	2012-01-01	972
2011: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	809
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	897
Total of all active and inactive participants	2011-01-01	897
Total participants	2011-01-01	897
2010: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	782
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	809
Total of all active and inactive participants	2010-01-01	809
Total participants	2010-01-01	809

Form 5500 Responses for SULLIVAN TIRE CO., INC GR MEDICAL PLAN

2022: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: SULLIVAN TIRE CO., INC GR 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: SULLIVAN TIRE CO., INC GR 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: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: SULLIVAN TIRE CO., INC GR 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: SULLIVAN TIRE CO., INC GR 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
2010: SULLIVAN TIRE CO., INC GR MEDICAL PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

00344474

Policy instance

Insurance contract or identification number	00344474
Number of Individuals Covered	261
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,892
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $60,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,670
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

KGA, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Insurance contract or identification number	0
Number of Individuals Covered	1186
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EAP
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $30,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	1142
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $23,529
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ADD
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $908,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,615
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

Policy instance

Number of Individuals Covered	1524
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $503,478
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,499,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $413,508
Insurance broker organization code?	5

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

Policy contract number

00344474

Policy instance

Insurance contract or identification number	00344474
Number of Individuals Covered	229
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $8,126
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,126
Insurance broker organization code?	3

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

Policy contract number

00910098

Policy instance

Insurance contract or identification number	00910098
Number of Individuals Covered	729
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,738
Other welfare benefits provided	SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $230,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $278
Insurance broker organization code?	3

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	1081
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $33,121
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $707,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,121
Insurance broker organization code?	3

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	1054
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $28,163
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $520,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,163
Insurance broker organization code?	3

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

Policy contract number

00344474

Policy instance

Insurance contract or identification number	00344474
Number of Individuals Covered	193
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,301
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,301
Insurance broker organization code?	3

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

Policy contract number

Policy instance

Number of Individuals Covered	1553
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $494,622
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,511,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $398,921
Insurance broker organization code?	5

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

Policy contract number

Policy instance

Number of Individuals Covered	1675
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $555,378
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,265,053
Amount paid for insurance broker fees	458147
Insurance broker organization code?	5

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

Policy contract number

00344474

Policy instance

Insurance contract or identification number	00344474
Number of Individuals Covered	200
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,286
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,416
Commission paid to Insurance Broker	USD $6,164
Insurance broker organization code?	3

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	1154
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $30,400
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $612,643
Commission paid to Insurance Broker	USD $30,400
Insurance broker organization code?	3

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

Policy contract number

Policy instance

Number of Individuals Covered	1744
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $444,774
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $879,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $346,080
Insurance broker organization code?	5

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

Policy contract number

00344474

Policy instance

Insurance contract or identification number	00344474
Number of Individuals Covered	188
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,905
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,890
Insurance broker organization code?	3

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	1128
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $31,345
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $651,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,345
Insurance broker organization code?	3

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

Policy contract number

Policy instance

Number of Individuals Covered	1754
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $425,685
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $737,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $326,980
Insurance broker organization code?	5
Insurance broker name	WELLESLEY INSURANCE AGENCY

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

Policy contract number

00344474

Policy instance

Insurance contract or identification number	00344474
Number of Individuals Covered	13
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,068
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,063
Insurance broker organization code?	3
Insurance broker name	BULFINCH GROUP INSURANCE AGENCY

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	1111
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $29,292
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $575,363
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,292
Insurance broker organization code?	3
Insurance broker name	STEPHEN J. BELL

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	1085
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $28,571
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $543,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,571
Insurance broker organization code?	3
Insurance broker name	STEPHEN J. BELL

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

Policy contract number

042231

Policy instance

Insurance contract or identification number	042231
Number of Individuals Covered	36
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,191
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $109,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,191
Insurance broker organization code?	3
Insurance broker name	WELLESLEY INSURANCE AGENCY

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

Policy contract number

042230

Policy instance

Insurance contract or identification number	042230
Number of Individuals Covered	1765
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $92,375
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,477,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $92,375
Insurance broker organization code?	3
Insurance broker name	WELLESLEY INSURANCE AGENCY

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

Policy contract number

00344474

Policy instance

Insurance contract or identification number	00344474
Number of Individuals Covered	15
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,177
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,171
Insurance broker organization code?	3
Insurance broker name	BULFINCH GROUP INSURANCE AGENCY

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	1024
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $28,519
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $526,006
Commission paid to Insurance Broker	USD $28,519
Insurance broker organization code?	3
Insurance broker name	STEPHEN J. BELL

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

Policy contract number

4008836

Policy instance

Insurance contract or identification number	4008836
Number of Individuals Covered	785
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $86,003
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,615,223
Commission paid to Insurance Broker	USD $86,003
Insurance broker organization code?	3
Insurance broker name	WELLESLEY INSURANCE AGENCY

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

Policy contract number

4008836

Policy instance

Insurance contract or identification number	4008836
Number of Individuals Covered	752
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $78,796
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,853,157
Commission paid to Insurance Broker	USD $78,796
Insurance broker organization code?	3
Insurance broker name	WELLESLEY INSURANCE AGENCY

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	1019
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $27,258
Total amount of fees paid to insurance company	USD $13,407
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $488,862
Commission paid to Insurance Broker	USD $27,258
Amount paid for insurance broker fees	13407
Insurance broker organization code?	3
Insurance broker name	STEPHEN J. BELL

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

Policy contract number

00344474

Policy instance

Insurance contract or identification number	00344474
Number of Individuals Covered	17
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,009
Total amount of fees paid to insurance company	USD $339
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,723
Commission paid to Insurance Broker	USD $1,004
Amount paid for insurance broker fees	339
Insurance broker organization code?	3
Insurance broker name	BULFINCH GROUP INSURANCE AGENCY

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

Policy contract number

00344474

Policy instance

Insurance contract or identification number	00344474
Number of Individuals Covered	18
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $886
Total amount of fees paid to insurance company	USD $317
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $882
Amount paid for insurance broker fees	317
Insurance broker organization code?	3
Insurance broker name	THE BULFINCH GRP INS AGEN

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

Policy contract number

4008836

Policy instance

Insurance contract or identification number	4008836
Number of Individuals Covered	767
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $72,211
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,243,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,211
Insurance broker organization code?	3
Insurance broker name	WELLESLEY INSURANCE AGENCY

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	1009
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $26,376
Total amount of fees paid to insurance company	USD $12,700
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $463,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,376
Amount paid for insurance broker fees	12700
Insurance broker organization code?	3
Insurance broker name	STEPHEN J. BELL

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	914
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $24,323
Total amount of fees paid to insurance company	USD $12,483
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $406,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

4008836

Policy instance

Insurance contract or identification number	4008836
Number of Individuals Covered	708
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $90,436
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,471,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00344474

Policy instance

Insurance contract or identification number	00344474
Number of Individuals Covered	17
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $827
Total amount of fees paid to insurance company	USD $297
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,330

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

Policy contract number

00311251

Policy instance

Insurance contract or identification number	00311251
Number of Individuals Covered	831
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $24,132
Total amount of fees paid to insurance company	USD $12,237
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $396,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,996
Amount paid for insurance broker fees	12237
Insurance broker organization code?	3
Insurance broker name	THE BULFINCH GRP. INS. AGENCY

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

Policy contract number

4008836

Policy instance

Insurance contract or identification number	4008836
Number of Individuals Covered	663
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $84,531
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,029,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84,531
Insurance broker organization code?	3
Insurance broker name	WELLESLEY INSURANCE AGENCY

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

Policy contract number

00344474

Policy instance

Insurance contract or identification number	00344474
Number of Individuals Covered	18
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $804
Total amount of fees paid to insurance company	USD $304
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $397
Amount paid for insurance broker fees	304
Insurance broker organization code?	3
Insurance broker name	THE BULLFINCH GROUP INSURANCE AGENC

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Company Name:	SULLIVAN INVESTMENT CO., INC.
Employer identification number (EIN):	042682840
NAIC Classification:	441300
NAIC Description:	Automotive Parts, Accessories, and Tire Stores