401k Plan data: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN plan

ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN
Plan identification number	501

ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS 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

401k Sponsoring company profile

TRI STATE TRUCK CENTER, LLC has sponsored the creation of one or more 401k plans.

Company Name: TRI STATE TRUCK CENTER, LLC

Employer identification number (EIN): 042840481

NAIC Classification: 484120
NAIC Description: General Freight Trucking, Long-Distance

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01

Plan Statistics for ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN

401k plan membership statisitcs for ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN

Measure Date Value
2023: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 299
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 350
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 350
2022: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 285
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 299
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 299
2021: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 183
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 285
Total of all active and inactive participants 2021-01-01 285
2020: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 157
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 183
Total of all active and inactive participants 2020-01-01 183
2019: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 205
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 207
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 207

Measure	Date	Value
2023: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	299
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	350
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	350
2022: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	285
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	299
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	299
2021: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	183
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	285
Total of all active and inactive participants	2021-01-01	285
2020: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	157
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	183
Total of all active and inactive participants	2020-01-01	183
2019: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	205
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	207
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	207

Form 5500 Responses for ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN

2023: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS 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: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS 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: ADVANTAGE TRUCK GROUP LLC HEALTH AND WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	First time form 5500 has been submitted	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

HI00000342053

Policy instance

Insurance contract or identification number	HI00000342053
Number of Individuals Covered	69
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $9,676
Total amount of fees paid to insurance company	USD $880
Welfare Benefit Premiums Paid to Carrier	USD $17,592
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

4958481

Policy instance

Insurance contract or identification number	4958481
Number of Individuals Covered	508
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $69,133
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,121,497
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

013158

Policy instance

Insurance contract or identification number	013158
Number of Individuals Covered	564
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,655
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $267,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

244136

Policy instance

Insurance contract or identification number	244136
Number of Individuals Covered	95
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $4,061
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $65,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1163505

Policy instance

Insurance contract or identification number	1163505
Number of Individuals Covered	519
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $3,042
Total amount of fees paid to insurance company	USD $578
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10272296

Policy instance

Insurance contract or identification number	10272296
Number of Individuals Covered	350
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $1,676
Total amount of fees paid to insurance company	USD $3,661
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $39,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10272297

Policy instance

Insurance contract or identification number	10272297
Number of Individuals Covered	350
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $1,969
Total amount of fees paid to insurance company	USD $6,253
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

400001000 27451

Policy instance

Insurance contract or identification number	400001000 27451
Number of Individuals Covered	271
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $7,434
Total amount of fees paid to insurance company	USD $6,093
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $72,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10272298

Policy instance

Insurance contract or identification number	10272298
Number of Individuals Covered	350
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $1,365
Total amount of fees paid to insurance company	USD $3,614
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

ACC-0000342052

Policy instance

Insurance contract or identification number	ACC-0000342052
Number of Individuals Covered	152
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $11,407
Total amount of fees paid to insurance company	USD $877
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $17,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

CI-0000342051

Policy instance

Insurance contract or identification number	CI-0000342051
Number of Individuals Covered	67
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $9,011
Total amount of fees paid to insurance company	USD $643
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $12,873
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

4958481

Policy instance

Insurance contract or identification number	4958481
Number of Individuals Covered	453
Insurance policy start date	2023-11-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $11,612
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $583,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,612
Insurance broker organization code?	3

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

Policy contract number

30043591

Policy instance

Insurance contract or identification number	30043591
Number of Individuals Covered	194
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $1,349
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $805
Insurance broker organization code?	3

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

Policy contract number

244136

Policy instance

Insurance contract or identification number	244136
Number of Individuals Covered	111
Insurance policy start date	2021-10-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $6,734
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $93,752
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,014
Insurance broker organization code?	3

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

Policy contract number

013158

Policy instance

Insurance contract or identification number	013158
Number of Individuals Covered	497
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $218,874
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

4958481

Policy instance

Insurance contract or identification number	4958481
Number of Individuals Covered	430
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $67,655
Total amount of fees paid to insurance company	USD $12,805
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,334,063
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,898
Amount paid for insurance broker fees	12805
Additional information about fees paid to insurance broker	OTHER COMMISSION
Insurance broker organization code?	3

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

Policy contract number

30043591

Policy instance

Insurance contract or identification number	30043591
Number of Individuals Covered	125
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $1,171
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,391
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

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

Policy contract number

244136

Policy instance

Insurance contract or identification number	244136
Number of Individuals Covered	122
Insurance policy start date	2020-03-31
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $12,101
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $172,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,819
Insurance broker organization code?	3

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

Policy contract number

013158

Policy instance

Insurance contract or identification number	013158
Number of Individuals Covered	458
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $6,561
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $190,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,561
Insurance broker organization code?	3

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

Policy contract number

4958481

Policy instance

Insurance contract or identification number	4958481
Number of Individuals Covered	394
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $61,738
Total amount of fees paid to insurance company	USD $11,700
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,876,063
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,738
Amount paid for insurance broker fees	11700
Additional information about fees paid to insurance broker	OTHER COMMISSION
Insurance broker organization code?	3

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

Policy contract number

4958481

Policy instance

Insurance contract or identification number	4958481
Number of Individuals Covered	380
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $55,988
Total amount of fees paid to insurance company	USD $5,495
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,497,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,988
Amount paid for insurance broker fees	5495
Additional information about fees paid to insurance broker	OTHER COMMISSION
Insurance broker organization code?	3

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

Policy contract number

013158

Policy instance

Insurance contract or identification number	013158
Number of Individuals Covered	408
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $7,640
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $159,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,640
Insurance broker organization code?	3

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

Policy contract number

244136

Policy instance

Insurance contract or identification number	244136
Number of Individuals Covered	192
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $8,493
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $109,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,493
Insurance broker organization code?	3

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

Policy contract number

30043591

Policy instance

Insurance contract or identification number	30043591
Number of Individuals Covered	153
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $793
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $793
Insurance broker organization code?	3

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

Policy contract number

30043591

Policy instance

Insurance contract or identification number	30043591
Number of Individuals Covered	120
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

244136

Policy instance

Insurance contract or identification number	244136
Number of Individuals Covered	132
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $5,341
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,341
Insurance broker organization code?	3

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

Policy contract number

013158

Policy instance

Insurance contract or identification number	013158
Number of Individuals Covered	358
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $5,516
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $143,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,516
Insurance broker organization code?	3

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

Policy contract number

4958481

Policy instance

Insurance contract or identification number	4958481
Number of Individuals Covered	342
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $52,685
Total amount of fees paid to insurance company	USD $2,767
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,277,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,685
Amount paid for insurance broker fees	2767
Additional information about fees paid to insurance broker	OTHER COMMISSION
Insurance broker organization code?	3

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Company Name:	TRI STATE TRUCK CENTER, LLC
Employer identification number (EIN):	042840481
NAIC Classification:	484120
NAIC Description:	General Freight Trucking, Long-Distance