401k Plan data: GREENS FARMS ACADEMY INC. WELFARE PLAN plan

GREENS FARMS ACADEMY INC. WELFARE PLAN 401k Plan overview

Plan Name	GREENS FARMS ACADEMY INC. WELFARE PLAN
Plan identification number	501

GREENS FARMS ACADEMY INC. WELFARE 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)

401k Sponsoring company profile

GREENS FARMS ACADEMY INC. has sponsored the creation of one or more 401k plans.

Company Name: GREENS FARMS ACADEMY INC.

Employer identification number (EIN): 060733693

NAIC Classification: 611000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GREENS FARMS ACADEMY INC. WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01
501 2021-07-01
501 2020-07-01
501 2019-07-01 KIM DICORPO 2020-10-16
501 2018-07-01 KIM DICORPO 2019-11-22
501 2017-07-01
501 2016-07-01
501 2015-07-01
501 2014-07-01
501 2013-07-01
501 2012-07-01 RUSSELL K. FRIEDSON
501 2010-07-01 RUSSELL K. FRIEDSON
501 2008-07-01 RUSSELL K. FRIEDSON
501 2007-07-01 RUSSELL K. FRIEDSON
501 2006-07-01 RUSSELL K. FRIEDSON
501 2005-07-01 RUSSELL K. FRIEDSON
501 2004-07-01 RUSSELL K. FRIEDSON

Plan Statistics for GREENS FARMS ACADEMY INC. WELFARE PLAN

401k plan membership statisitcs for GREENS FARMS ACADEMY INC. WELFARE PLAN

Measure Date Value
2022: GREENS FARMS ACADEMY INC. WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 190
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 180
Number of retired or separated participants receiving benefits 2022-07-01 2
Number of other retired or separated participants entitled to future benefits 2022-07-01 0
Total of all active and inactive participants 2022-07-01 182
2021: GREENS FARMS ACADEMY INC. WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 189
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 187
Number of retired or separated participants receiving benefits 2021-07-01 3
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 190
2020: GREENS FARMS ACADEMY INC. WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 187
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 187
Number of retired or separated participants receiving benefits 2020-07-01 2
Number of other retired or separated participants entitled to future benefits 2020-07-01 0
Total of all active and inactive participants 2020-07-01 189
2019: GREENS FARMS ACADEMY INC. WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 185
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 184
Number of retired or separated participants receiving benefits 2019-07-01 3
Total of all active and inactive participants 2019-07-01 187
2018: GREENS FARMS ACADEMY INC. WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 172
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 185
Total of all active and inactive participants 2018-07-01 185
2017: GREENS FARMS ACADEMY INC. WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 180
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 172
Total of all active and inactive participants 2017-07-01 172
2016: GREENS FARMS ACADEMY INC. WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 173
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 180
Total of all active and inactive participants 2016-07-01 180
2015: GREENS FARMS ACADEMY INC. WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 168
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 173
Total of all active and inactive participants 2015-07-01 173
2014: GREENS FARMS ACADEMY INC. WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 166
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 168
Total of all active and inactive participants 2014-07-01 168
2013: GREENS FARMS ACADEMY INC. WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 134
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 166
Total of all active and inactive participants 2013-07-01 166
2012: GREENS FARMS ACADEMY INC. WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 154
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 134
Total of all active and inactive participants 2012-07-01 134
2010: GREENS FARMS ACADEMY INC. WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-07-01 146
Total number of active participants reported on line 7a of the Form 5500 2010-07-01 144
Total of all active and inactive participants 2010-07-01 144
2008: GREENS FARMS ACADEMY INC. WELFARE PLAN 2008 401k membership
Total participants, beginning-of-year 2008-07-01 120
Total number of active participants reported on line 7a of the Form 5500 2008-07-01 146
Total of all active and inactive participants 2008-07-01 146
2007: GREENS FARMS ACADEMY INC. WELFARE PLAN 2007 401k membership
Total participants, beginning-of-year 2007-07-01 120
Total number of active participants reported on line 7a of the Form 5500 2007-07-01 120
Total of all active and inactive participants 2007-07-01 120
2006: GREENS FARMS ACADEMY INC. WELFARE PLAN 2006 401k membership
Total participants, beginning-of-year 2006-07-01 120
Total number of active participants reported on line 7a of the Form 5500 2006-07-01 120
Total of all active and inactive participants 2006-07-01 120
2005: GREENS FARMS ACADEMY INC. WELFARE PLAN 2005 401k membership
Total participants, beginning-of-year 2005-07-01 120
Total number of active participants reported on line 7a of the Form 5500 2005-07-01 120
Total of all active and inactive participants 2005-07-01 120
2004: GREENS FARMS ACADEMY INC. WELFARE PLAN 2004 401k membership
Total participants, beginning-of-year 2004-07-01 105
Total number of active participants reported on line 7a of the Form 5500 2004-07-01 120
Total of all active and inactive participants 2004-07-01 120

Measure	Date	Value
2022: GREENS FARMS ACADEMY INC. WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	190
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	180
Number of retired or separated participants receiving benefits	2022-07-01	2
Number of other retired or separated participants entitled to future benefits	2022-07-01	0
Total of all active and inactive participants	2022-07-01	182
2021: GREENS FARMS ACADEMY INC. WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	189
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	187
Number of retired or separated participants receiving benefits	2021-07-01	3
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	190
2020: GREENS FARMS ACADEMY INC. WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	187
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	187
Number of retired or separated participants receiving benefits	2020-07-01	2
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	189
2019: GREENS FARMS ACADEMY INC. WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	185
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	184
Number of retired or separated participants receiving benefits	2019-07-01	3
Total of all active and inactive participants	2019-07-01	187
2018: GREENS FARMS ACADEMY INC. WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	172
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	185
Total of all active and inactive participants	2018-07-01	185
2017: GREENS FARMS ACADEMY INC. WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	180
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	172
Total of all active and inactive participants	2017-07-01	172
2016: GREENS FARMS ACADEMY INC. WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	173
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	180
Total of all active and inactive participants	2016-07-01	180
2015: GREENS FARMS ACADEMY INC. WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	168
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	173
Total of all active and inactive participants	2015-07-01	173
2014: GREENS FARMS ACADEMY INC. WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	166
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	168
Total of all active and inactive participants	2014-07-01	168
2013: GREENS FARMS ACADEMY INC. WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	134
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	166
Total of all active and inactive participants	2013-07-01	166
2012: GREENS FARMS ACADEMY INC. WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	154
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	134
Total of all active and inactive participants	2012-07-01	134
2010: GREENS FARMS ACADEMY INC. WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-07-01	146
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	144
Total of all active and inactive participants	2010-07-01	144
2008: GREENS FARMS ACADEMY INC. WELFARE PLAN 2008 401k membership
Total participants, beginning-of-year	2008-07-01	120
Total number of active participants reported on line 7a of the Form 5500	2008-07-01	146
Total of all active and inactive participants	2008-07-01	146
2007: GREENS FARMS ACADEMY INC. WELFARE PLAN 2007 401k membership
Total participants, beginning-of-year	2007-07-01	120
Total number of active participants reported on line 7a of the Form 5500	2007-07-01	120
Total of all active and inactive participants	2007-07-01	120
2006: GREENS FARMS ACADEMY INC. WELFARE PLAN 2006 401k membership
Total participants, beginning-of-year	2006-07-01	120
Total number of active participants reported on line 7a of the Form 5500	2006-07-01	120
Total of all active and inactive participants	2006-07-01	120
2005: GREENS FARMS ACADEMY INC. WELFARE PLAN 2005 401k membership
Total participants, beginning-of-year	2005-07-01	120
Total number of active participants reported on line 7a of the Form 5500	2005-07-01	120
Total of all active and inactive participants	2005-07-01	120
2004: GREENS FARMS ACADEMY INC. WELFARE PLAN 2004 401k membership
Total participants, beginning-of-year	2004-07-01	105
Total number of active participants reported on line 7a of the Form 5500	2004-07-01	120
Total of all active and inactive participants	2004-07-01	120

Form 5500 Responses for GREENS FARMS ACADEMY INC. WELFARE PLAN

2022: GREENS FARMS ACADEMY INC. WELFARE PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Submission has been amended	No
2022-07-01	This submission is the final filing	No
2022-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-07-01	Plan is a collectively bargained plan	No
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: GREENS FARMS ACADEMY INC. WELFARE PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Submission has been amended	No
2021-07-01	This submission is the final filing	No
2021-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-07-01	Plan is a collectively bargained plan	No
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: GREENS FARMS ACADEMY INC. WELFARE PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Submission has been amended	No
2020-07-01	This submission is the final filing	No
2020-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-07-01	Plan is a collectively bargained plan	No
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2019: GREENS FARMS ACADEMY INC. WELFARE PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2018: GREENS FARMS ACADEMY INC. WELFARE PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: GREENS FARMS ACADEMY INC. WELFARE PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2016: GREENS FARMS ACADEMY INC. WELFARE PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2015: GREENS FARMS ACADEMY INC. WELFARE PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2014: GREENS FARMS ACADEMY INC. WELFARE PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: GREENS FARMS ACADEMY INC. WELFARE PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2012: GREENS FARMS ACADEMY INC. WELFARE PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2010: GREENS FARMS ACADEMY INC. WELFARE PLAN 2010 form 5500 responses
2010-07-01	Type of plan entity	Single employer plan
2010-07-01	Plan funding arrangement – Insurance	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes
2008: GREENS FARMS ACADEMY INC. WELFARE PLAN 2008 form 5500 responses
2008-07-01	Type of plan entity	Single employer plan
2008-07-01	Plan funding arrangement – Insurance	Yes
2008-07-01	Plan benefit arrangement – Insurance	Yes
2007: GREENS FARMS ACADEMY INC. WELFARE PLAN 2007 form 5500 responses
2007-07-01	Type of plan entity	Single employer plan
2007-07-01	Plan funding arrangement – Insurance	Yes
2007-07-01	Plan benefit arrangement – Insurance	Yes
2006: GREENS FARMS ACADEMY INC. WELFARE PLAN 2006 form 5500 responses
2006-07-01	Type of plan entity	Single employer plan
2006-07-01	Plan funding arrangement – Insurance	Yes
2006-07-01	Plan benefit arrangement – Insurance	Yes
2005: GREENS FARMS ACADEMY INC. WELFARE PLAN 2005 form 5500 responses
2005-07-01	Type of plan entity	Single employer plan
2005-07-01	Plan funding arrangement – Insurance	Yes
2005-07-01	Plan benefit arrangement – Insurance	Yes
2004: GREENS FARMS ACADEMY INC. WELFARE PLAN 2004 form 5500 responses
2004-07-01	Type of plan entity	Single employer plan
2004-07-01	Plan funding arrangement – Insurance	Yes
2004-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98808991001

Policy instance

Insurance contract or identification number	98808991001
Number of Individuals Covered	193
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $1,124
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,124
Insurance broker organization code?	3

DELTA DENTAL OF CT, INC. (National Association of Insurance Commissioners NAIC id number: 15987 )

Policy contract number

04051-20,

Policy instance

Insurance contract or identification number	04051-20,
Number of Individuals Covered	293
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $2,891
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,891
Insurance broker organization code?	3

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

Policy contract number

223570

Policy instance

Insurance contract or identification number	223570
Number of Individuals Covered	181
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $4,469
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $70,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,469
Insurance broker organization code?	3

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

Policy contract number

11085111005

Policy instance

Insurance contract or identification number	11085111005
Number of Individuals Covered	313
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $41,954
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,062,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,954
Insurance broker organization code?	3

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

Policy contract number

11085111005

Policy instance

Insurance contract or identification number	11085111005
Number of Individuals Covered	326
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $43,481
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,082,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,481
Insurance broker organization code?	3

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

Policy contract number

223570

Policy instance

Insurance contract or identification number	223570
Number of Individuals Covered	187
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $5,584
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $63,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,584
Insurance broker organization code?	3

DELTA DENTAL OF CT, INC. (National Association of Insurance Commissioners NAIC id number: 15987 )

Policy contract number

04051-20, 1020

Policy instance

Insurance contract or identification number	04051-20, 1020
Number of Individuals Covered	299
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $2,788
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,788
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98808991001

Policy instance

Insurance contract or identification number	98808991001
Number of Individuals Covered	207
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,217
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,218
Insurance broker organization code?	3

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

Policy contract number

11085111005

Policy instance

Insurance contract or identification number	11085111005
Number of Individuals Covered	326
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $38,586
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,904,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,586
Insurance broker organization code?	3

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

Policy contract number

223570

Policy instance

Insurance contract or identification number	223570
Number of Individuals Covered	187
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $5,357
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $70,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,357
Insurance broker organization code?	3

DELTA DENTAL OF CT, INC. (National Association of Insurance Commissioners NAIC id number: 15987 )

Policy contract number

04051-20, 1020

Policy instance

Insurance contract or identification number	04051-20, 1020
Number of Individuals Covered	298
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $2,793
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,793
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98808991001

Policy instance

Insurance contract or identification number	98808991001
Number of Individuals Covered	198
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,141
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,137
Insurance broker organization code?	3

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

Policy contract number

1483

Policy instance

Insurance contract or identification number	1483
Number of Individuals Covered	332
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $41,007
Total amount of fees paid to insurance company	USD $2,923
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,697,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,007
Amount paid for insurance broker fees	2923
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

223570

Policy instance

Insurance contract or identification number	223570
Number of Individuals Covered	184
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $5,235
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $64,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,628
Insurance broker organization code?	3

DELTA DENTAL OF CT, INC. (National Association of Insurance Commissioners NAIC id number: 15987 )

Policy contract number

04051-20, 1020

Policy instance

Insurance contract or identification number	04051-20, 1020
Number of Individuals Covered	291
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $2,705
Total amount of fees paid to insurance company	USD $0
Dental 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 $2,705
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98808991001

Policy instance

Insurance contract or identification number	98808991001
Number of Individuals Covered	187
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,135
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $724
Insurance broker organization code?	3

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

Policy contract number

1483

Policy instance

Insurance contract or identification number	1483
Number of Individuals Covered	321
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $38,770
Total amount of fees paid to insurance company	USD $1,363
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,485,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,770
Amount paid for insurance broker fees	1363
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

223570

Policy instance

Insurance contract or identification number	223570
Number of Individuals Covered	185
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $5,306
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $64,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,306
Insurance broker organization code?	3

DELTA DENTAL OF CT, INC. (National Association of Insurance Commissioners NAIC id number: 15987 )

Policy contract number

04051-20, 1020

Policy instance

Insurance contract or identification number	04051-20, 1020
Number of Individuals Covered	301
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $2,759
Total amount of fees paid to insurance company	USD $0
Dental 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 $2,759
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98808991001

Policy instance

Insurance contract or identification number	98808991001
Number of Individuals Covered	177
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $840
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $840
Insurance broker organization code?	3

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

Policy contract number

1483

Policy instance

Insurance contract or identification number	1483
Number of Individuals Covered	288
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $32,459
Total amount of fees paid to insurance company	USD $2,091
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,080,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

C12333

Policy instance

Insurance contract or identification number	C12333
Number of Individuals Covered	10
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,203
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,149
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

4051-20-120

Policy instance

Insurance contract or identification number	4051-20-120
Number of Individuals Covered	0
Insurance policy start date	2017-07-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $1,710
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
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

223570

Policy instance

Insurance contract or identification number	223570
Number of Individuals Covered	172
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $4,722
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $59,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF CT, INC. (National Association of Insurance Commissioners NAIC id number: 15987 )

Policy contract number

04051-20, 1020

Policy instance

Insurance contract or identification number	04051-20, 1020
Number of Individuals Covered	306
Insurance policy start date	2018-02-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $897
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
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: 71870 )

Policy contract number

98808991001

Policy instance

Insurance contract or identification number	98808991001
Number of Individuals Covered	169
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $855
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,259
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

223570

Policy instance

Insurance contract or identification number	223570
Number of Individuals Covered	173
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $6,281
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $63,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,281
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT, LLC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

4051-20-120

Policy instance

Insurance contract or identification number	4051-20-120
Number of Individuals Covered	130
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $2,628
Total amount of fees paid to insurance company	USD $0
Dental 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 $2,628
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT, LLC

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

Policy contract number

1483

Policy instance

Insurance contract or identification number	1483
Number of Individuals Covered	278
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $28,381
Total amount of fees paid to insurance company	USD $1,209
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,819,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,381
Amount paid for insurance broker fees	1209
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT, LLC

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

C12333

Policy instance

Insurance contract or identification number	C12333
Number of Individuals Covered	21
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $2,368
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $178,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,368
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT, LLC

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

Policy contract number

223570

Policy instance

Insurance contract or identification number	223570
Number of Individuals Covered	168
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $4,180
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
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $59,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,180
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT, LLC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

4051-20-120

Policy instance

Insurance contract or identification number	4051-20-120
Number of Individuals Covered	132
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $143
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $143
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT, LLC

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

Policy contract number

1483

Policy instance

Insurance contract or identification number	1483
Number of Individuals Covered	266
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $25,744
Total amount of fees paid to insurance company	USD $1,444
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 $1,650,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,744
Amount paid for insurance broker fees	1444
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT, LLC

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

C12333

Policy instance

Insurance contract or identification number	C12333
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 $3,738
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 $239,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,738
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT, LLC

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

C12333

Policy instance

Insurance contract or identification number	C12333
Number of Individuals Covered	29
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $3,375
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 $237,749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,375
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT LLC

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

Policy contract number

1483

Policy instance

Insurance contract or identification number	1483
Number of Individuals Covered	262
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $23,554
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 $1,549,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,554
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT LLC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

4051-20-120

Policy instance

Insurance contract or identification number	4051-20-120
Number of Individuals Covered	131
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $3,678
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,678
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT LLC

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

Policy contract number

223570

Policy instance

Insurance contract or identification number	223570
Number of Individuals Covered	166
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,488
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $36,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,488
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT LLC

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

Policy contract number

861242G

Policy instance

Insurance contract or identification number	861242G
Number of Individuals Covered	120
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $4,902
Total amount of fees paid to insurance company	USD $270
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 $15,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,902
Amount paid for insurance broker fees	270
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	FRANK CRYSTAL & CO INC

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

4051-20-120

Policy instance

Insurance contract or identification number	4051-20-120
Number of Individuals Covered	128
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,475
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
Dental 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 $3,475
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT LLC

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

Policy contract number

1483

Policy instance

Insurance contract or identification number	1483
Number of Individuals Covered	256
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $20,495
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 $1,322,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $20,495
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT LLC

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

C12333

Policy instance

Insurance contract or identification number	C12333
Number of Individuals Covered	38
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,734
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $240,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,734
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT LLC

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

CI2333

Policy instance

Insurance contract or identification number	CI2333
Number of Individuals Covered	33
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $2,946
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 $179,628
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

1483

Policy instance

Insurance contract or identification number	1483
Number of Individuals Covered	238
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $19,232
Total amount of fees paid to insurance company	USD $754
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 $1,172,691
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

1483

Policy instance

Insurance contract or identification number	1483
Number of Individuals Covered	230
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $17,786
Total amount of fees paid to insurance company	USD $686
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 $1,071,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

CU2333

Policy instance

Insurance contract or identification number	CU2333
Number of Individuals Covered	31
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $3,686
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 $222,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

C12333

Policy instance

Insurance contract or identification number	C12333
Number of Individuals Covered	28
Insurance policy start date	2009-07-01
Insurance policy end date	2010-06-30
Total amount of commissions paid to insurance broker	USD $2,739
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 $142,193
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

1483

Policy instance

Insurance contract or identification number	1483
Insurance policy start date	2009-07-01
Insurance policy end date	2010-06-30
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

Policy instance

Insurance policy start date	2008-07-01
Insurance policy end date	2009-06-30
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

C12333

Policy instance

Insurance contract or identification number	C12333
Number of Individuals Covered	36
Insurance policy start date	2008-07-01
Insurance policy end date	2009-06-30
Total amount of commissions paid to insurance broker	USD $4,315
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 $198,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,315
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT LLC

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

C12333

Policy instance

Insurance contract or identification number	C12333
Number of Individuals Covered	49
Insurance policy start date	2007-07-01
Insurance policy end date	2008-06-30
Total amount of commissions paid to insurance broker	USD $3,889
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 $251,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,889
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT LLC

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

Policy contract number

1483

Policy instance

Insurance contract or identification number	1483
Insurance policy start date	2007-07-01
Insurance policy end date	2008-06-30
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

1483

Policy instance

Insurance contract or identification number	1483
Insurance policy start date	2006-07-01
Insurance policy end date	2007-06-30
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

C12333

Policy instance

Insurance contract or identification number	C12333
Number of Individuals Covered	57
Insurance policy start date	2006-07-01
Insurance policy end date	2007-06-30
Total amount of commissions paid to insurance broker	USD $5,002
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 $226,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,002
Insurance broker organization code?	3
Insurance broker name	WILLIS OF CONNECTICUT LLC

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

Policy contract number

143

Policy instance

Insurance contract or identification number	143
Insurance policy start date	2005-07-01
Insurance policy end date	2006-06-30
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

C12333

Policy instance

Insurance contract or identification number	C12333
Number of Individuals Covered	57
Insurance policy start date	2005-07-01
Insurance policy end date	2006-06-30
Total amount of commissions paid to insurance broker	USD $4,957
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 $242,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,753
Insurance broker organization code?	3
Insurance broker name	HILB ROGAL AND HAMILTON COM OF CT

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

C12333

Policy instance

Insurance contract or identification number	C12333
Number of Individuals Covered	158
Insurance policy start date	2004-07-01
Insurance policy end date	2005-06-30
Total amount of commissions paid to insurance broker	USD $10,060
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 $525,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,060
Insurance broker organization code?	3
Insurance broker name	HILB ROGAL AND HAMILTON COM OF CT

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Company Name:	GREENS FARMS ACADEMY INC.
Employer identification number (EIN):	060733693
NAIC Classification:	611000