401k Plan data: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN plan

HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN
Plan identification number	506

HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

BAIM INSTITUTE FOR CLINICAL RESEARCH INC. has sponsored the creation of one or more 401k plans.

Company Name: BAIM INSTITUTE FOR CLINICAL RESEARCH INC.

Employer identification number (EIN): 043521077

NAIC Classification: 541700

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2023-01-01 VICTORIA HALPRIN 2024-09-17 VICTORIA HALPRIN 2024-09-17
506 2022-01-01 SUE FRITZ 2023-09-29 SUE FRITZ 2023-09-29
506 2021-01-01 SUE FRITZ 2022-09-20 SUE FRITZ 2022-09-20
506 2020-01-01 ROBERT LOEB 2021-07-29 ROBERT LOEB 2021-07-29
506 2019-01-01 ROBERT LOEB 2020-09-16 ROBERT LOEB 2020-09-16
506 2018-01-01
506 2017-01-01
506 2016-01-01
506 2015-01-01
506 2014-01-01 ROBERT LOEB ROBERT LOEB 2015-09-28
506 2013-01-01 ROBERT LOEB ROBERT LOEB 2014-08-27
506 2012-01-01 ROBERT LOEB ROBERT LOEB 2013-09-11
506 2011-01-01 ROBERT LOEB ROBERT LOEB 2012-08-08
506 2010-01-01 ROBERT LOEB ROBERT LOEB 2011-07-14
506 2009-01-01 ROBERT LOEB ROBERT LOEB 2010-10-13
506 2009-01-01 ROBERT LOEB ROBERT LOEB 2010-10-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
506	2023-01-01	VICTORIA HALPRIN	2024-09-17	VICTORIA HALPRIN	2024-09-17
506	2022-01-01	SUE FRITZ	2023-09-29	SUE FRITZ	2023-09-29
506	2021-01-01	SUE FRITZ	2022-09-20	SUE FRITZ	2022-09-20
506	2020-01-01	ROBERT LOEB	2021-07-29	ROBERT LOEB	2021-07-29
506	2019-01-01	ROBERT LOEB	2020-09-16	ROBERT LOEB	2020-09-16
506	2018-01-01
506	2017-01-01
506	2016-01-01
506	2015-01-01
506	2014-01-01	ROBERT LOEB		ROBERT LOEB	2015-09-28
506	2013-01-01	ROBERT LOEB		ROBERT LOEB	2014-08-27
506	2012-01-01	ROBERT LOEB		ROBERT LOEB	2013-09-11
506	2011-01-01	ROBERT LOEB		ROBERT LOEB	2012-08-08
506	2010-01-01	ROBERT LOEB		ROBERT LOEB	2011-07-14
506	2009-01-01	ROBERT LOEB		ROBERT LOEB	2010-10-13
506	2009-01-01	ROBERT LOEB		ROBERT LOEB	2010-10-13

Plan Statistics for HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN

401k plan membership statisitcs for HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN

Measure Date Value
2023: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 49
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 65
Total of all active and inactive participants 2023-01-01 65
2022: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 61
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 49
Total of all active and inactive participants 2022-01-01 49
2021: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 81
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 61
Total of all active and inactive participants 2021-01-01 61
2020: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 80
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 81
Total of all active and inactive participants 2020-01-01 81
2019: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 87
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 80
Total of all active and inactive participants 2019-01-01 80
2018: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 99
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 87
Total of all active and inactive participants 2018-01-01 87
2017: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 122
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 99
Total of all active and inactive participants 2017-01-01 99
2016: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 178
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 122
Total of all active and inactive participants 2016-01-01 122
2015: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 162
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 178
Total of all active and inactive participants 2015-01-01 178
2014: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 162
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 154
Number of retired or separated participants receiving benefits 2014-01-01 9
Total of all active and inactive participants 2014-01-01 163
2013: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 159
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 162
Total of all active and inactive participants 2013-01-01 162
2012: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 159
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 152
Number of retired or separated participants receiving benefits 2012-01-01 7
Total of all active and inactive participants 2012-01-01 159
2011: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 175
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 168
Number of retired or separated participants receiving benefits 2011-01-01 3
Total of all active and inactive participants 2011-01-01 171
2010: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 141
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 181
Number of retired or separated participants receiving benefits 2010-01-01 3
Total of all active and inactive participants 2010-01-01 184
Total participants 2010-01-01 184
2009: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 146
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 151
Number of retired or separated participants receiving benefits 2009-01-01 5
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 156

Measure	Date	Value
2023: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	49
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	65
Total of all active and inactive participants	2023-01-01	65
2022: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	61
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	49
Total of all active and inactive participants	2022-01-01	49
2021: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	81
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	61
Total of all active and inactive participants	2021-01-01	61
2020: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	80
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	81
Total of all active and inactive participants	2020-01-01	81
2019: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	87
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	80
Total of all active and inactive participants	2019-01-01	80
2018: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	99
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	87
Total of all active and inactive participants	2018-01-01	87
2017: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	122
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	99
Total of all active and inactive participants	2017-01-01	99
2016: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	178
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	122
Total of all active and inactive participants	2016-01-01	122
2015: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	162
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	178
Total of all active and inactive participants	2015-01-01	178
2014: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	162
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	154
Number of retired or separated participants receiving benefits	2014-01-01	9
Total of all active and inactive participants	2014-01-01	163
2013: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	159
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	162
Total of all active and inactive participants	2013-01-01	162
2012: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	159
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	152
Number of retired or separated participants receiving benefits	2012-01-01	7
Total of all active and inactive participants	2012-01-01	159
2011: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	175
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	168
Number of retired or separated participants receiving benefits	2011-01-01	3
Total of all active and inactive participants	2011-01-01	171
2010: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	181
Number of retired or separated participants receiving benefits	2010-01-01	3
Total of all active and inactive participants	2010-01-01	184
Total participants	2010-01-01	184
2009: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	146
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	151
Number of retired or separated participants receiving benefits	2009-01-01	5
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	156

Form 5500 Responses for HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN

2023: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: HARVARD CLINICAL RESEARCH INSTITUTE WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	17
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $4,292
Total amount of fees paid to insurance company	USD $952
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $180,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	65
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $9,802
Total amount of fees paid to insurance company	USD $4,813
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $375,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	53
Insurance policy start date	2023-01-01
Insurance policy end date	2024-01-01
Total amount of commissions paid to insurance broker	USD $3,160
Total amount of fees paid to insurance company	USD $1,529
Other welfare benefits provided	PAID FAMILY MEDICAL LEAVE
Welfare Benefit Premiums Paid to Carrier	USD $33,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	56
Insurance policy start date	2023-01-01
Insurance policy end date	2024-01-01
Total amount of commissions paid to insurance broker	USD $973
Total amount of fees paid to insurance company	USD $535
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	56
Insurance policy start date	2023-01-01
Insurance policy end date	2024-01-01
Total amount of commissions paid to insurance broker	USD $717
Total amount of fees paid to insurance company	USD $391
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	56
Insurance policy start date	2023-01-01
Insurance policy end date	2024-01-01
Total amount of commissions paid to insurance broker	USD $1,727
Total amount of fees paid to insurance company	USD $623
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	11
Insurance policy start date	2023-01-01
Insurance policy end date	2024-01-01
Total amount of commissions paid to insurance broker	USD $281
Total amount of fees paid to insurance company	USD $70
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $1,873
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

013874

Policy instance

Insurance contract or identification number	013874
Number of Individuals Covered	81
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,010
Total amount of fees paid to insurance company	USD $102
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

154933

Policy instance

Insurance contract or identification number	154933
Number of Individuals Covered	1
Insurance policy start date	2023-01-01
Insurance policy end date	2024-01-01
Total amount of commissions paid to insurance broker	USD $17
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	49
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,963
Total amount of fees paid to insurance company	USD $4,813
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $348,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,963
Amount paid for insurance broker fees	4813
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	13
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,297
Total amount of fees paid to insurance company	USD $952
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $109,316
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,297
Amount paid for insurance broker fees	952
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	48
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $911
Total amount of fees paid to insurance company	USD $511
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $911
Amount paid for insurance broker fees	511
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	48
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $1,549
Total amount of fees paid to insurance company	USD $624
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,549
Amount paid for insurance broker fees	624
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	9
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $138
Total amount of fees paid to insurance company	USD $129
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $138
Amount paid for insurance broker fees	129
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	48
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $648
Total amount of fees paid to insurance company	USD $399
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $648
Amount paid for insurance broker fees	399
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

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

Policy contract number

013874

Policy instance

Insurance contract or identification number	013874
Number of Individuals Covered	67
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,459
Total amount of fees paid to insurance company	USD $216
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,459
Amount paid for insurance broker fees	216
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

154933

Policy instance

Insurance contract or identification number	154933
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $25
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	49
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $3,202
Total amount of fees paid to insurance company	USD $1,728
Other welfare benefits provided	PAID FAMILY MEDICAL LEAVE
Welfare Benefit Premiums Paid to Carrier	USD $34,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,202
Amount paid for insurance broker fees	1728
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	50
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $832
Total amount of fees paid to insurance company	USD $1,570
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $832
Amount paid for insurance broker fees	1570
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	10
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,492
Total amount of fees paid to insurance company	USD $860
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,492
Amount paid for insurance broker fees	860
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	61
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,976
Total amount of fees paid to insurance company	USD $8,155
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $431,381
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,976
Amount paid for insurance broker fees	8155
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

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

Policy contract number

013874

Policy instance

Insurance contract or identification number	013874
Number of Individuals Covered	73
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,610
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,610
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	50
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $670
Total amount of fees paid to insurance company	USD $463
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,698
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $670
Amount paid for insurance broker fees	463
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	50
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,563
Total amount of fees paid to insurance company	USD $799
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,563
Amount paid for insurance broker fees	799
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	10
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $332
Total amount of fees paid to insurance company	USD $147
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $2,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $332
Amount paid for insurance broker fees	147
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

114684

Policy instance

Insurance contract or identification number	114684
Number of Individuals Covered	2
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $114
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $114
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

154933

Policy instance

Insurance contract or identification number	154933
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $35
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	60
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,631
Total amount of fees paid to insurance company	USD $2,468
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,631
Amount paid for insurance broker fees	2468
Additional information about fees paid to insurance broker	INSUARANCE AGENT OR BROKER
Insurance broker organization code?	3

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	81
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $13,132
Total amount of fees paid to insurance company	USD $6,246
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $579,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,132
Amount paid for insurance broker fees	6246
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	6
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,792
Total amount of fees paid to insurance company	USD $823
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,792
Amount paid for insurance broker fees	823
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	53
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,542
Total amount of fees paid to insurance company	USD $748
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,542
Amount paid for insurance broker fees	748
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	54
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $716
Total amount of fees paid to insurance company	USD $209
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $716
Amount paid for insurance broker fees	209
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	54
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,869
Total amount of fees paid to insurance company	USD $366
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,869
Amount paid for insurance broker fees	366
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	13
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $339
Total amount of fees paid to insurance company	USD $69
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $339
Amount paid for insurance broker fees	69
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

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

Policy contract number

013874

Policy instance

Insurance contract or identification number	013874
Number of Individuals Covered	89
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,482
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,482
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

114684

Policy instance

Insurance contract or identification number	114684
Number of Individuals Covered	2
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $67
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

154933

Policy instance

Insurance contract or identification number	154933
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $43
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $899
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
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	80
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $13,019
Total amount of fees paid to insurance company	USD $5,669
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $520,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,019
Amount paid for insurance broker fees	5669
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	10
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,988
Total amount of fees paid to insurance company	USD $1,017
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,988
Amount paid for insurance broker fees	1017
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	65
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,494
Total amount of fees paid to insurance company	USD $1,127
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,494
Amount paid for insurance broker fees	1127
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	55
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $697
Total amount of fees paid to insurance company	USD $309
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $697
Amount paid for insurance broker fees	309
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	55
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,830
Total amount of fees paid to insurance company	USD $547
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,201
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,830
Amount paid for insurance broker fees	547
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	55
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $344
Total amount of fees paid to insurance company	USD $157
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $344
Amount paid for insurance broker fees	157
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

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

Policy contract number

013874

Policy instance

Insurance contract or identification number	013874
Number of Individuals Covered	96
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,153
Total amount of fees paid to insurance company	USD $138
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,153
Amount paid for insurance broker fees	138
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

114684

Policy instance

Insurance contract or identification number	114684
Number of Individuals Covered	2
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $93
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $93
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

154933

Policy instance

Insurance contract or identification number	154933
Number of Individuals Covered	1
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $54
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54
Additional information about fees paid to insurance broker	INSURANCE FEES
Insurance broker organization code?	3

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	87
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $19,410
Total amount of fees paid to insurance company	USD $11,083
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $566,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,410
Amount paid for insurance broker fees	11083
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	7
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,834
Total amount of fees paid to insurance company	USD $3,641
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,834
Amount paid for insurance broker fees	3641
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	53
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,928
Total amount of fees paid to insurance company	USD $2,705
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,928
Amount paid for insurance broker fees	2705
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	53
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $802
Total amount of fees paid to insurance company	USD $735
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $802
Amount paid for insurance broker fees	735
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	53
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,133
Total amount of fees paid to insurance company	USD $1,308
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,133
Amount paid for insurance broker fees	1308
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	14
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $617
Total amount of fees paid to insurance company	USD $382
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $617
Amount paid for insurance broker fees	382
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

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

Policy contract number

013874

Policy instance

Insurance contract or identification number	013874
Number of Individuals Covered	93
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,094
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,094
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

114684

Policy instance

Insurance contract or identification number	114684
Number of Individuals Covered	3
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $132
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,850
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $132
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

154933

Policy instance

Insurance contract or identification number	154933
Number of Individuals Covered	3
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $95
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $95
Additional information about fees paid to insurance broker	INSURANCE AGENT OR BROKER
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	20
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,180
Total amount of fees paid to insurance company	USD $246
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,180
Amount paid for insurance broker fees	246
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EASTERN INSURANCE GROUP LLC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	99
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,350
Total amount of fees paid to insurance company	USD $1,210
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,350
Amount paid for insurance broker fees	1210
Additional information about fees paid to insurance broker	OTHE COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EASTERN INSURANCE GROUP LLC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	99
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,518
Total amount of fees paid to insurance company	USD $682
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,518
Amount paid for insurance broker fees	682
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EASTERN INSURANCE GROUP LLC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AYR5

Policy instance

Insurance contract or identification number	G000AYR5
Number of Individuals Covered	99
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,147
Total amount of fees paid to insurance company	USD $2,484
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,147
Amount paid for insurance broker fees	2484
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	EASTERN INSURANCE GROUP LLC

TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	31
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,792
Total amount of fees paid to insurance company	USD $3,296
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $303,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,792
Amount paid for insurance broker fees	3296
Additional information about fees paid to insurance broker	ANNUAL BONUSES
Insurance broker organization code?	3
Insurance broker name	EASTERN INSURANCE GROUP LLC

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

150817105358

Policy instance

Insurance contract or identification number	150817105358
Number of Individuals Covered	140
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $24,831
Total amount of fees paid to insurance company	USD $10,707
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $923,619
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,831
Amount paid for insurance broker fees	10707
Additional information about fees paid to insurance broker	ANNUAL BONUSES
Insurance broker organization code?	3
Insurance broker name	EASTERN INSURANCE GROUP LLC

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

Policy contract number

013874

Policy instance

Insurance contract or identification number	013874
Number of Individuals Covered	166
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,456
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,456
Insurance broker organization code?	3
Insurance broker name	EASTERN INSURANCE GROUP LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

154933

Policy instance

Insurance contract or identification number	154933
Number of Individuals Covered	6
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $408
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	408
Insurance broker organization code?	3
Insurance broker name	EASTERN INSURANCE GROUP LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

114684

Policy instance

Insurance contract or identification number	114684
Number of Individuals Covered	9
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $268
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $268
Insurance broker organization code?	3
Insurance broker name	EASTERN INSURANCE GROUP LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

114684

Policy instance

Insurance contract or identification number	114684
Number of Individuals Covered	21
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $743
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $743
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	31
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $301
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $301
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	45
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,704
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,704
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	163
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,701
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,701
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	137
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,009
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,009
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

154933

Policy instance

Insurance contract or identification number	154933
Number of Individuals Covered	8
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $867
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $867
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

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

Policy contract number

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	286
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $34,952
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,786,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,952
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

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

Policy contract number

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	274
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,647
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $160,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,647
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	137
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,283
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $28,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,283
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	170
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,720
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,720
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	50
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,874
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,874
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

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

Policy contract number

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	294
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,734
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $163,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,734
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	170
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,814
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,814
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

114684

Policy instance

Insurance contract or identification number	114684
Number of Individuals Covered	26
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $497
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $497
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	207
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $10,636
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,636
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	37
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $51
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

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

Policy contract number

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	303
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $34,810
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,769,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,810
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	160
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $10,863
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,863
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	31
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,513
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,513
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	18
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $165
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $165
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	159
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,560
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,560
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

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

Policy contract number

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	297
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,921
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $173,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,921
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

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

Policy contract number

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	301
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $35,852
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,868,201
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,852
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

114684

Policy instance

Insurance contract or identification number	114684
Number of Individuals Covered	26
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $598
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $598
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	161
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,146
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,146
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	173
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $12,843
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,843
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

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

Policy contract number

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	319
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $36,271
Total amount of fees paid to insurance company	USD $18,179
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,910,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,271
Amount paid for insurance broker fees	18179
Additional information about fees paid to insurance broker	BONUS AND PERSISTENCY COMMISSION PAID TO BROKER BY BCBSMA NOT BILLED
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

114684

Policy instance

Insurance contract or identification number	114684
Number of Individuals Covered	29
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $571
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $571
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	173
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,253
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,253
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	21
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $139
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $139
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	34
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,298
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,298
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	39
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $891
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $891
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	173
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $13,438
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,438
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

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

Policy contract number

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	322
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,068
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $180,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,068
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	191
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $10,073
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,363
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	40
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,793
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	26
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $123
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	183
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,536
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

114684

Policy instance

Insurance contract or identification number	114684
Number of Individuals Covered	36
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,127
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,462
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

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	327
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $35,796
Total amount of fees paid to insurance company	USD $15,159
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,866,940
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

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	329
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,072
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $181,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50003780

Policy instance

Insurance contract or identification number	50003780
Number of Individuals Covered	220
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $11,261
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,304
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

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	317
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,796
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $167,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,796
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

6688

Policy instance

Insurance contract or identification number	6688
Number of Individuals Covered	191
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $7,911
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,911
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

6688

Policy instance

Insurance contract or identification number	6688
Number of Individuals Covered	195
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $9,530
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,530
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

6688

Policy instance

Insurance contract or identification number	6688
Number of Individuals Covered	23
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,757
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,757
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

6688

Policy instance

Insurance contract or identification number	6688
Number of Individuals Covered	24
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $112
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $112
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

6688

Policy instance

Insurance contract or identification number	6688
Number of Individuals Covered	195
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,360
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,360
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

114684

Policy instance

Insurance contract or identification number	114684
Number of Individuals Covered	41
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,953
Total amount of fees paid to insurance company	USD $553
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,953
Amount paid for insurance broker fees	232
Additional information about fees paid to insurance broker	FEES PAID AS ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	UNITED STATES LIFE INSURANCE CO.

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05584925

Policy instance

Insurance contract or identification number	TM05584925
Number of Individuals Covered	0
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $209
Total amount of fees paid to insurance company	USD $239
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $209
Amount paid for insurance broker fees	239
Insurance broker organization code?	3
Insurance broker name	EASTERN INS GROUP LLC

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

Policy contract number

4945539

Policy instance

Insurance contract or identification number	4945539
Number of Individuals Covered	323
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $29,423
Total amount of fees paid to insurance company	USD $14,922
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,645,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,423
Amount paid for insurance broker fees	14922
Additional information about fees paid to insurance broker	BONUS AND PERSISTENCY COMMISSIONS PAID TO BROKER BY BCBSMA NOT BILLEO
Insurance broker organization code?	3
Insurance broker name	EASTERN INSURANCE GROUP LLC

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Company Name:	BAIM INSTITUTE FOR CLINICAL RESEARCH INC.
Employer identification number (EIN):	043521077
NAIC Classification:	541700