401k Plan data: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN plan

LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 401k Plan overview

Plan Name	LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN
Plan identification number	512

LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN Benefits

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

401k Sponsoring company profile

WATERBURY HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name: WATERBURY HOSPITAL

Employer identification number (EIN): 060665979

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
512 2016-01-01 CARL SHERTER
512 2015-01-01
512 2014-01-01
512 2013-01-01
512 2012-01-01 MARK MCKENNA
512 2011-01-01 MARK MCKENNA
512 2009-01-01 CHRISTINE THOMAS-MELLY

Plan Statistics for LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN

401k plan membership statisitcs for LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN

Measure Date Value
2016: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,349
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
2015: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,402
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,327
Number of retired or separated participants receiving benefits 2015-01-01 22
Total of all active and inactive participants 2015-01-01 1,349
2014: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,113
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,384
Number of retired or separated participants receiving benefits 2014-01-01 18
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 1,402
2013: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,253
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,086
Number of retired or separated participants receiving benefits 2013-01-01 27
Total of all active and inactive participants 2013-01-01 1,113
2012: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,323
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1,221
Number of retired or separated participants receiving benefits 2012-01-01 32
Total of all active and inactive participants 2012-01-01 1,253
2011: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,894
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,292
Number of retired or separated participants receiving benefits 2011-01-01 31
Total of all active and inactive participants 2011-01-01 1,323
2009: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 1,807
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 1,689
Number of retired or separated participants receiving benefits 2009-01-01 56
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 1,745

Measure	Date	Value
2016: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,349
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
2015: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,402
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,327
Number of retired or separated participants receiving benefits	2015-01-01	22
Total of all active and inactive participants	2015-01-01	1,349
2014: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,113
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,384
Number of retired or separated participants receiving benefits	2014-01-01	18
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	1,402
2013: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,253
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,086
Number of retired or separated participants receiving benefits	2013-01-01	27
Total of all active and inactive participants	2013-01-01	1,113
2012: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,323
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,221
Number of retired or separated participants receiving benefits	2012-01-01	32
Total of all active and inactive participants	2012-01-01	1,253
2011: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,894
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,292
Number of retired or separated participants receiving benefits	2011-01-01	31
Total of all active and inactive participants	2011-01-01	1,323
2009: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	1,807
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	1,689
Number of retired or separated participants receiving benefits	2009-01-01	56
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	1,745

Form 5500 Responses for LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN

2016: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	Yes
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: LIFE, ACCIDENT & SICKNESS, DENTAL & COMPREHENSIVE MEDICAL PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

00415931

Policy instance

Insurance contract or identification number	00415931
Number of Individuals Covered	36
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $561
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $220
Insurance broker organization code?	3
Insurance broker name	MW FINANCIAL GROUP LTD

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU4380655

Policy instance

Insurance contract or identification number	GTU4380655
Number of Individuals Covered	2024
Insurance policy start date	2013-10-01
Insurance policy end date	2016-10-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TRAVEL AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

221056

Policy instance

Insurance contract or identification number	221056
Number of Individuals Covered	1043
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $15,327
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $468,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,327
Insurance broker organization code?	3
Insurance broker name	C.M. SMITH AGENCY INC.

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

153940

Policy instance

Insurance contract or identification number	153940
Number of Individuals Covered	1119
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,259
Total amount of fees paid to insurance company	USD $8,122
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,259
Amount paid for insurance broker fees	8122
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	C.M. SMITH AGENCY INC.

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

153940

Policy instance

Insurance contract or identification number	153940
Number of Individuals Covered	969
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,471
Total amount of fees paid to insurance company	USD $3,774
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,471
Amount paid for insurance broker fees	3774
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	C.M. SMITH AGENCY INC.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ADDS07698

Policy instance

Insurance contract or identification number	ADDS07698
Number of Individuals Covered	642
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

402659G

Policy instance

Insurance contract or identification number	402659G
Number of Individuals Covered	1577
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BTRM, SDEP, VOL
Welfare Benefit Premiums Paid to Carrier	USD $144,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0517078

Policy instance

Insurance contract or identification number	R0517078
Number of Individuals Covered	118
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $16,100
Total amount of fees paid to insurance company	USD $129
Other welfare benefits provided	CRITICAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $50,393
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,100
Amount paid for insurance broker fees	129
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	C.M. SMITH AGENCY INC.

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

9800137

Policy instance

Insurance contract or identification number	9800137
Number of Individuals Covered	1557
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00415931

Policy instance

Insurance contract or identification number	00415931
Number of Individuals Covered	12
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $281
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 $1,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $110
Insurance broker organization code?	3
Insurance broker name	MW FINANCIAL GROUP LTD

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

9800137

Policy instance

Insurance contract or identification number	9800137
Number of Individuals Covered	1971
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $78,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

221056

Policy instance

Insurance contract or identification number	221056
Number of Individuals Covered	2205
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,312
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
Welfare Benefit Premiums Paid to Carrier	USD $354,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,312
Insurance broker organization code?	3
Insurance broker name	C.M. SMITH AGENCY INC.

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

153940

Policy instance

Insurance contract or identification number	153940
Number of Individuals Covered	1104
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $19,530
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
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,274
Insurance broker organization code?	3
Insurance broker name	C.M. SMITH AGENCY INC.

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

153940

Policy instance

Insurance contract or identification number	153940
Number of Individuals Covered	1169
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $26,884
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,035
Insurance broker organization code?	3
Insurance broker name	C.M. SMITH AGENCY INC.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ADDS07698

Policy instance

Insurance contract or identification number	ADDS07698
Number of Individuals Covered	598
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

402659G

Policy instance

Insurance contract or identification number	402659G
Number of Individuals Covered	1717
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $4,199
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
Other welfare benefits provided	BTRM, SDEP, VOL
Welfare Benefit Premiums Paid to Carrier	USD $132,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4199
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	C.M. SMITH AGENCY INC.

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU4380655

Policy instance

Insurance contract or identification number	GTU4380655
Number of Individuals Covered	2024
Insurance policy start date	2013-10-01
Insurance policy end date	2016-10-01
Total amount of commissions paid to insurance broker	USD $675
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
Other welfare benefits provided	TRAVEL AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $675
Insurance broker name	MERCER HEALTH & BENEFITS

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3330206

Policy instance

Insurance contract or identification number	3330206
Number of Individuals Covered	1024
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $36,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

153940

Policy instance

Insurance contract or identification number	153940
Number of Individuals Covered	1270
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $21,791
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,898
Insurance broker organization code?	3
Insurance broker name	C.M. SMITH AGENCY INC.

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

153940

Policy instance

Insurance contract or identification number	153940
Number of Individuals Covered	1188
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $24,021
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,671
Insurance broker organization code?	3
Insurance broker name	C.M. SMITH AGENCY INC.

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

Policy contract number

221056

Policy instance

Insurance contract or identification number	221056
Number of Individuals Covered	2974
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,863
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
Welfare Benefit Premiums Paid to Carrier	USD $930,824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,863
Insurance broker organization code?	3
Insurance broker name	C.M. SMITH AGENCY INC.

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

9800137

Policy instance

Insurance contract or identification number	9800137
Number of Individuals Covered	1914
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX962858

Policy instance

Insurance contract or identification number	FLX962858
Number of Individuals Covered	1086
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPP LIFE, DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $181,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00415931

Policy instance

Insurance contract or identification number	00415931
Number of Individuals Covered	63
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,200
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 $7,846
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $471
Insurance broker organization code?	3
Insurance broker name	MW FINANCIAL GROUP LTD

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3330206

Policy instance

Insurance contract or identification number	3330206
Number of Individuals Covered	1024
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $22,619
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $36,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	22619
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker organization code?	3
Insurance broker name	C.M. SMITH AGENCY INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK964518

Policy instance

Insurance contract or identification number	OK964518
Number of Individuals Covered	1086
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $11,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU4370655

Policy instance

Insurance contract or identification number	GTU4370655
Number of Individuals Covered	1880
Insurance policy start date	2011-04-04
Insurance policy end date	2013-10-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	TRAVEL AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU4370655

Policy instance

Insurance contract or identification number	GTU4370655
Number of Individuals Covered	1880
Insurance policy start date	2011-04-04
Insurance policy end date	2013-10-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	TRAVEL AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

133090

Policy instance

Insurance contract or identification number	133090
Number of Individuals Covered	1562
Insurance policy start date	2012-01-01
Insurance policy end date	2012-03-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $165,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3330206

Policy instance

Insurance contract or identification number	3330206
Number of Individuals Covered	0
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $-597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00415931

Policy instance

Insurance contract or identification number	00415931
Number of Individuals Covered	63
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $1,118
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 $7,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $438
Insurance broker organization code?	3
Insurance broker name	MW FINANCIAL GROUP, LTD.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX962858

Policy instance

Insurance contract or identification number	FLX962858
Number of Individuals Covered	1221
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPP LIFE, DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $193,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

9809435

Policy instance

Insurance contract or identification number	9809435
Number of Individuals Covered	30
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

9800137

Policy instance

Insurance contract or identification number	9800137
Number of Individuals Covered	1963
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK964518

Policy instance

Insurance contract or identification number	OK964518
Number of Individuals Covered	1221
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $12,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK964518

Policy instance

Insurance contract or identification number	OK964518
Number of Individuals Covered	737
Insurance policy start date	2011-01-01
Insurance policy end date	2012-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $13,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

133090

Policy instance

Insurance contract or identification number	12294080
Number of Individuals Covered	4469
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $928,983

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3330206

Policy instance

Insurance contract or identification number	3330206
Number of Individuals Covered	1270
Insurance policy start date	2011-01-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $415,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

GTU4370655

Policy instance

Insurance contract or identification number	GTU4370655
Number of Individuals Covered	1880
Insurance policy start date	2011-04-04
Insurance policy end date	2013-10-01
Total amount of commissions paid to insurance broker	USD $492
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
Other welfare benefits provided	TRAVEL AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00415931

Policy instance

Insurance contract or identification number	00415931
Number of Individuals Covered	63
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $1,118
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 $7,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX962858

Policy instance

Insurance contract or identification number	FLX962858
Number of Individuals Covered	1494
Insurance policy start date	2011-01-01
Insurance policy end date	2012-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPP LIFE, DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $204,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

9800137

Policy instance

Insurance contract or identification number	9800137
Number of Individuals Covered	1865
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 )

Policy contract number

1158

Policy instance

Insurance contract or identification number	1158
Number of Individuals Covered	2661
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $176,914
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 $14,058,144
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

ABL621515

Policy instance

Insurance contract or identification number	ABL621515
Number of Individuals Covered	1755
Insurance policy start date	2007-10-01
Insurance policy end date	2010-10-01
Total amount of commissions paid to insurance broker	USD $3
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
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
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
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX962858

Policy instance

Insurance contract or identification number	FLX962858
Number of Individuals Covered	2115
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPP LIFE, DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $199,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00415931

Policy instance

Insurance contract or identification number	00415931
Number of Individuals Covered	66
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,122
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 $7,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $440
Insurance broker organization code?	3
Insurance broker name	MW FINANCIAL GROUP, LTD.

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3330206

Policy instance

Insurance contract or identification number	3330206
Number of Individuals Covered	1266
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,002,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK964518

Policy instance

Insurance contract or identification number	OK964518
Number of Individuals Covered	958
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $13,226
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

96240

Policy instance

Insurance contract or identification number	96240
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $27
Total amount of fees paid to insurance company	USD $27
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 $236
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
Amount paid for insurance broker fees	21
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	NEIL BALLOTTE

CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 )

Policy contract number

005562

Policy instance

Insurance contract or identification number	005562
Number of Individuals Covered	2189
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $130,475
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 $11,593,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $130,475
Insurance broker organization code?	3
Insurance broker name	THE SEGAL COMPANY

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

Policy contract number

133090

Policy instance

Insurance contract or identification number	133090
Number of Individuals Covered	1715
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $880,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	WATERBURY HOSPITAL
Employer identification number (EIN):	060665979
NAIC Classification:	622000
NAIC Description:	Hospitals

Plan id#	Filing Submission Date	Name of Administrator
512	2016-01-01	CARL SHERTER
512	2015-01-01
512	2014-01-01
512	2013-01-01
512	2012-01-01	MARK MCKENNA
512	2011-01-01	MARK MCKENNA
512	2009-01-01	CHRISTINE THOMAS-MELLY