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THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 401k Plan overview

Plan NameTHOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA
Plan identification number 501

THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA Benefits

401k Plan TypeWelfare 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

THOMAS H LEE MANAGEMENT CO, LLC has sponsored the creation of one or more 401k plans.

Company Name:THOMAS H LEE MANAGEMENT CO, LLC
Employer identification number (EIN):043475841
NAIC Classification:523900

Additional information about THOMAS H LEE MANAGEMENT CO, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 3065819

More information about THOMAS H LEE MANAGEMENT CO, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-06-01MICHAEL MCDONNELL2023-12-20
5012021-06-01MICHAEL MCDONNELL2022-12-09
5012020-06-01MICHAEL MCDONNELL2021-11-23
5012019-06-01MICHAEL MCDONNELL2020-12-01
5012018-06-01CHARLES HOLDEN2019-12-04
5012017-06-01CHARLES HOLDEN
5012016-06-01LAURIE VIDETTA
5012015-06-01LAURIE VIDETTA
5012014-06-01LAURIE VIDETTA
5012013-06-01LAURIE VIDETTA
5012012-06-01LAURIE VIDETTA
5012011-06-01LAURIE VIDETTA
5012009-06-01LAURIE VIDETTA LAURIE VIDETTA2010-12-22

Plan Statistics for THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA

401k plan membership statisitcs for THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA

Measure Date Value
2022: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2022 401k membership
Total participants, beginning-of-year2022-06-01143
Total number of active participants reported on line 7a of the Form 55002022-06-01164
Number of retired or separated participants receiving benefits2022-06-012
Number of other retired or separated participants entitled to future benefits2022-06-010
Total of all active and inactive participants2022-06-01166
2021: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2021 401k membership
Total participants, beginning-of-year2021-06-01135
Total number of active participants reported on line 7a of the Form 55002021-06-01141
Number of retired or separated participants receiving benefits2021-06-012
Number of other retired or separated participants entitled to future benefits2021-06-010
Total of all active and inactive participants2021-06-01143
2020: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2020 401k membership
Total participants, beginning-of-year2020-06-01128
Total number of active participants reported on line 7a of the Form 55002020-06-01130
Number of retired or separated participants receiving benefits2020-06-015
Number of other retired or separated participants entitled to future benefits2020-06-010
Total of all active and inactive participants2020-06-01135
2019: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2019 401k membership
Total participants, beginning-of-year2019-06-01108
Total number of active participants reported on line 7a of the Form 55002019-06-01123
Number of retired or separated participants receiving benefits2019-06-015
Number of other retired or separated participants entitled to future benefits2019-06-010
Total of all active and inactive participants2019-06-01128
2018: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2018 401k membership
Total participants, beginning-of-year2018-06-01114
Total number of active participants reported on line 7a of the Form 55002018-06-01113
Number of retired or separated participants receiving benefits2018-06-017
Number of other retired or separated participants entitled to future benefits2018-06-010
Total of all active and inactive participants2018-06-01120
2017: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2017 401k membership
Total participants, beginning-of-year2017-06-01101
Total number of active participants reported on line 7a of the Form 55002017-06-01108
Number of retired or separated participants receiving benefits2017-06-016
Total of all active and inactive participants2017-06-01114
2016: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2016 401k membership
Total participants, beginning-of-year2016-06-01167
Total number of active participants reported on line 7a of the Form 55002016-06-01101
Total of all active and inactive participants2016-06-01101
2015: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2015 401k membership
Total participants, beginning-of-year2015-06-01161
Total number of active participants reported on line 7a of the Form 55002015-06-01167
Total of all active and inactive participants2015-06-01167
2014: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2014 401k membership
Total participants, beginning-of-year2014-06-01162
Total number of active participants reported on line 7a of the Form 55002014-06-01161
Total of all active and inactive participants2014-06-01161
2013: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2013 401k membership
Total participants, beginning-of-year2013-06-01162
Total number of active participants reported on line 7a of the Form 55002013-06-01162
Total of all active and inactive participants2013-06-01162
2012: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2012 401k membership
Total participants, beginning-of-year2012-06-01134
Total number of active participants reported on line 7a of the Form 55002012-06-01162
Number of retired or separated participants receiving benefits2012-06-010
Number of other retired or separated participants entitled to future benefits2012-06-010
Total of all active and inactive participants2012-06-01162
2011: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2011 401k membership
Total participants, beginning-of-year2011-06-01120
Total number of active participants reported on line 7a of the Form 55002011-06-01134
Number of retired or separated participants receiving benefits2011-06-010
Number of other retired or separated participants entitled to future benefits2011-06-010
Total of all active and inactive participants2011-06-01134
2009: THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2009 401k membership
Total participants, beginning-of-year2009-06-01114
Total number of active participants reported on line 7a of the Form 55002009-06-01109
Number of retired or separated participants receiving benefits2009-06-010
Number of other retired or separated participants entitled to future benefits2009-06-010
Total of all active and inactive participants2009-06-01109

Financial Data on THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA

Measure Date Value
2018 : THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2018 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2018-05-31No
Was this plan covered by a fidelity bond2018-05-31No
If this is an individual account plan, was there a blackout period2018-05-31No
Were there any nonexempt tranactions with any party-in-interest2018-05-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2018-05-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2018-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2018-05-31No
Were any leases to which the plan was party in default or uncollectible2018-05-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2018-05-31No
Was there a failure to transmit to the plan any participant contributions2018-05-31No
Has the plan failed to provide any benefit when due under the plan2018-05-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32018-05-31No
Did the plan have assets held for investment2018-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2018-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2018-05-31No
2017 : THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2017 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2017-05-31No
Was this plan covered by a fidelity bond2017-05-31No
If this is an individual account plan, was there a blackout period2017-05-31No
Were there any nonexempt tranactions with any party-in-interest2017-05-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2017-05-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2017-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2017-05-31No
Were any leases to which the plan was party in default or uncollectible2017-05-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2017-05-31No
Was there a failure to transmit to the plan any participant contributions2017-05-31No
Has the plan failed to provide any benefit when due under the plan2017-05-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32017-05-31No
Did the plan have assets held for investment2017-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2017-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2017-05-31No
2016 : THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2016 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2016-05-31No
Was this plan covered by a fidelity bond2016-05-31No
If this is an individual account plan, was there a blackout period2016-05-31No
Were there any nonexempt tranactions with any party-in-interest2016-05-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2016-05-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2016-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2016-05-31No
Were any leases to which the plan was party in default or uncollectible2016-05-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2016-05-31No
Was there a failure to transmit to the plan any participant contributions2016-05-31No
Has the plan failed to provide any benefit when due under the plan2016-05-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32016-05-31No
Did the plan have assets held for investment2016-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2016-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2016-05-31No
2015 : THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2015 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2015-05-31No
Was this plan covered by a fidelity bond2015-05-31No
If this is an individual account plan, was there a blackout period2015-05-31No
Were there any nonexempt tranactions with any party-in-interest2015-05-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2015-05-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2015-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2015-05-31No
Were any leases to which the plan was party in default or uncollectible2015-05-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2015-05-31No
Was there a failure to transmit to the plan any participant contributions2015-05-31No
Has the plan failed to provide any benefit when due under the plan2015-05-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32015-05-31No
Did the plan have assets held for investment2015-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2015-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2015-05-31No
2014 : THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA 2014 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2014-05-31No
Was this plan covered by a fidelity bond2014-05-31No
If this is an individual account plan, was there a blackout period2014-05-31No
Were there any nonexempt tranactions with any party-in-interest2014-05-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2014-05-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2014-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2014-05-31No
Were any leases to which the plan was party in default or uncollectible2014-05-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2014-05-31No
Was there a failure to transmit to the plan any participant contributions2014-05-31No
Has the plan failed to provide any benefit when due under the plan2014-05-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32014-05-31No
Did the plan have assets held for investment2014-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2014-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2014-05-31No

Form 5500 Responses for THOMAS H LEE MANAGEMENT CO, LLC GROUP BENEFITS PLA

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

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 4
Insurance contract or identification number0206540
Number of Individuals Covered407
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $6,334
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,334
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99139061001
Policy instance 3
Insurance contract or identification number99139061001
Number of Individuals Covered161
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $1,427
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,427
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 2
Insurance contract or identification number0206540
Number of Individuals Covered409
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $45,119
Total amount of fees paid to insurance companyUSD $17,085
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $45,119
Amount paid for insurance broker fees17085
Additional information about fees paid to insurance brokerBONUS & PERSISTENCY COMMISSIONS
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 1
Insurance contract or identification number07091
Number of Individuals Covered164
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $25,908
Total amount of fees paid to insurance companyUSD $29
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $165,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,908
Insurance broker organization code?3
Amount paid for insurance broker fees29
Additional information about fees paid to insurance brokerTPA FEES
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 1
Insurance contract or identification number07091
Number of Individuals Covered141
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $11,682
Total amount of fees paid to insurance companyUSD $18
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $162,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,682
Insurance broker organization code?3
Amount paid for insurance broker fees18
Additional information about fees paid to insurance brokerTPA FEES
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 2
Insurance contract or identification number0206540
Number of Individuals Covered343
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $40,540
Total amount of fees paid to insurance companyUSD $14,193
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,540
Amount paid for insurance broker fees14193
Additional information about fees paid to insurance brokerBONUS & PERSISTENCY COMMISSIONS
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99139061001
Policy instance 3
Insurance contract or identification number99139061001
Number of Individuals Covered107
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $1,166
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,166
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 4
Insurance contract or identification number0206540
Number of Individuals Covered337
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $5,746
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,746
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 1
Insurance contract or identification number07091
Number of Individuals Covered130
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $9,102
Total amount of fees paid to insurance companyUSD $24
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $155,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,102
Insurance broker organization code?3
Amount paid for insurance broker fees24
Additional information about fees paid to insurance brokerTPA FEES
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 2
Insurance contract or identification number0206540
Number of Individuals Covered344
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $35,579
Total amount of fees paid to insurance companyUSD $12,892
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,579
Amount paid for insurance broker fees12892
Additional information about fees paid to insurance brokerBONUS & PERSISTENCY COMMISSIONS
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99139061001
Policy instance 3
Insurance contract or identification number99139061001
Number of Individuals Covered86
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $887
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $9,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $887
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 4
Insurance contract or identification number0206540
Number of Individuals Covered338
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $5,705
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,705
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 1
Insurance contract or identification number07091
Number of Individuals Covered119
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $9,031
Total amount of fees paid to insurance companyUSD $36
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $119,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,031
Insurance broker organization code?3
Amount paid for insurance broker fees28
Additional information about fees paid to insurance brokerTPA FEES
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 2
Insurance contract or identification number0206540
Number of Individuals Covered315
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $34,389
Total amount of fees paid to insurance companyUSD $7,897
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,389
Amount paid for insurance broker fees7897
Additional information about fees paid to insurance brokerBONUS & PERSISTENCY COMMISSIONS
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99139061001
Policy instance 3
Insurance contract or identification number99139061001
Number of Individuals Covered68
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $765
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $803
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 4
Insurance contract or identification number0206540
Number of Individuals Covered306
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $5,608
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,608
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 1
Insurance contract or identification number07091
Number of Individuals Covered113
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $8,824
Total amount of fees paid to insurance companyUSD $40
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $141,199
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,824
Insurance broker organization code?3
Amount paid for insurance broker fees40
Additional information about fees paid to insurance brokerTPA FEES
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 2
Insurance contract or identification number0206540
Number of Individuals Covered308
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $40,078
Total amount of fees paid to insurance companyUSD $7,320
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,903,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,271
Amount paid for insurance broker fees7320
Additional information about fees paid to insurance brokerBONUS & PERSISTENCY COMMISSIONS
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99139061001
Policy instance 3
Insurance contract or identification number99139061001
Number of Individuals Covered64
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $1,536
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,478
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99139061001
Policy instance 4
Insurance contract or identification number99139061001
Number of Individuals Covered66
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,606
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,606
Insurance broker organization code?3
Insurance broker nameBRUCE CROHN, LLC
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 3
Insurance contract or identification number0206540
Number of Individuals Covered305
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $5,154
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,154
Insurance broker organization code?3
Insurance broker nameBRUCE CROHN, LLC
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 2
Insurance contract or identification number0206540
Number of Individuals Covered313
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $35,279
Total amount of fees paid to insurance companyUSD $6,540
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,279
Amount paid for insurance broker fees6540
Additional information about fees paid to insurance brokerPERSISTENCY BONUS
Insurance broker organization code?3
Insurance broker nameBRUCE CROHN, LLC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 1
Insurance contract or identification number07091
Number of Individuals Covered108
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $8,835
Total amount of fees paid to insurance companyUSD $37
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $141,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,835
Insurance broker organization code?3
Amount paid for insurance broker fees37
Additional information about fees paid to insurance brokerTPA FEES
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 1
Insurance contract or identification number07091
Number of Individuals Covered159
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $12,085
Total amount of fees paid to insurance companyUSD $57
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $413,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,085
Insurance broker organization code?3
Amount paid for insurance broker fees57
Additional information about fees paid to insurance brokerTPA FEES
Insurance broker nameAXA ASSISTANCE, USA
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 2
Insurance contract or identification number0206540
Number of Individuals Covered468
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $67,885
Total amount of fees paid to insurance companyUSD $12,300
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $67,885
Amount paid for insurance broker fees12300
Additional information about fees paid to insurance brokerPERSISTENCY BONUS
Insurance broker organization code?3
Insurance broker nameBRUCE CROHN, LLC
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 3
Insurance contract or identification number0206540
Number of Individuals Covered459
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $6,506
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,506
Insurance broker organization code?3
Insurance broker nameBRUCE CROHN, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9913906
Policy instance 4
Insurance contract or identification number9913906
Number of Individuals Covered128
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $1,204
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,204
Insurance broker organization code?3
Insurance broker nameBRUCE CROHN, LLC
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 3
Insurance contract or identification number0206540
Number of Individuals Covered160
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $6,364
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,364
Insurance broker organization code?3
Insurance broker nameBRUCE CROHN
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 1
Insurance contract or identification number07091
Number of Individuals Covered158
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $10,287
Total amount of fees paid to insurance companyUSD $57
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $452,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,287
Insurance broker organization code?3
Amount paid for insurance broker fees57
Additional information about fees paid to insurance brokerTPA FEES
Insurance broker nameAXA ASSISTANCE, USA
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 2
Insurance contract or identification number0206540
Number of Individuals Covered161
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $65,633
Total amount of fees paid to insurance companyUSD $6,427
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $65,633
Amount paid for insurance broker fees6427
Additional information about fees paid to insurance brokerPERSISTENCY BONUS
Insurance broker organization code?3
Insurance broker nameBRUCE CROHN, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9913906
Policy instance 4
Insurance contract or identification number9913906
Number of Individuals Covered109
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $768
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $768
Insurance broker organization code?3
Insurance broker nameBRUCE CROHN
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 1
Insurance contract or identification number07091
Number of Individuals Covered157
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $10,210
Total amount of fees paid to insurance companyUSD $56
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $437,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,320
Insurance broker organization code?4
Amount paid for insurance broker fees56
Additional information about fees paid to insurance brokerTPA FEES
Insurance broker nameAXA ASSISTANCE, USA
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 2
Insurance contract or identification number0206540
Number of Individuals Covered467
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $67,368
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $50,400
Insurance broker organization code?4
Insurance broker nameBRUCE CROHN, LLC
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 3
Insurance contract or identification number0206540
Number of Individuals Covered457
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $6,216
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,261
Insurance broker organization code?3
Insurance broker nameBRUCE CROHN
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 2
Insurance contract or identification number07091
Number of Individuals Covered158
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $12,627
Total amount of fees paid to insurance companyUSD $56
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD & D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,878
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE USA
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 1
Insurance contract or identification number0206540
Number of Individuals Covered162
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $73,060
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,481,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $73,060
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
Insurance broker nameRUSSELL J CARPENTIERI
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 2
Insurance contract or identification number07091
Number of Individuals Covered134
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $9,169
Total amount of fees paid to insurance companyUSD $46
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD & D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $316,808
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 number0206540
Policy instance 1
Insurance contract or identification number0206540
Number of Individuals Covered134
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $58,203
Total amount of fees paid to insurance companyUSD $13,949
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,185,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number042-2881-00
Policy instance 5
Insurance contract or identification number042-2881-00
Number of Individuals Covered81
Insurance policy start date2010-06-01
Insurance policy end date2010-07-01
Total amount of commissions paid to insurance brokerUSD $1,149
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $9,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 4
Insurance contract or identification number07091
Number of Individuals Covered120
Insurance policy start date2010-07-01
Insurance policy end date2010-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $63,368
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 number0206540
Policy instance 1
Insurance contract or identification number0206540
Number of Individuals Covered327
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $5,701
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number0206540
Policy instance 2
Insurance contract or identification number0206540
Number of Individuals Covered348
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $43,733
Total amount of fees paid to insurance companyUSD $11,464
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07091
Policy instance 3
Insurance contract or identification number07091
Number of Individuals Covered120
Insurance policy start date2010-07-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $8,045
Total amount of fees paid to insurance companyUSD $35
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $45,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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