401k Plan data: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN plan

JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 401k Plan overview

Plan Name	JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN
Plan identification number	501

JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN Benefits

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

401k Sponsoring company profile

THE JEWISH HOME FOR THE ELDERLY has sponsored the creation of one or more 401k plans.

Company Name: THE JEWISH HOME FOR THE ELDERLY

Employer identification number (EIN): 060846991

NAIC Classification: 813000
NAIC Description: Religious, Grantmaking, Civic, Professional, and Similar Organizations

Form 5500 Filing Information

Submission information for form 5500 for 401k plan JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 ROGER SLIBY 2023-10-11
501 2021-01-01 ROGER SLIBY 2023-07-12
501 2020-01-01
501 2019-01-01 ROGER SILBY 2020-09-03
501 2018-01-01 ROGER SLIBY 2019-09-26
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 ANDREW H. BANOFF
501 2011-01-01 LINDA CISZKOWSKI
501 2010-01-01 LINDA CISZKOWSKI
501 2009-01-01 LINDA C CISZKOWSKI

Plan Statistics for JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN

401k plan membership statisitcs for JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN

Measure Date Value
2022: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 448
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 455
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 455
2021: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 455
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 434
Number of retired or separated participants receiving benefits 2021-01-01 6
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 440
2020: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 459
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 454
Number of retired or separated participants receiving benefits 2020-01-01 4
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 458
2019: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 479
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 459
Total of all active and inactive participants 2019-01-01 459
2018: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 489
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 479
Total of all active and inactive participants 2018-01-01 479
2017: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 496
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 489
Total of all active and inactive participants 2017-01-01 489
2016: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 464
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 496
Total of all active and inactive participants 2016-01-01 496
2015: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 480
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 464
Total of all active and inactive participants 2015-01-01 464
2014: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 480
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 480
Total of all active and inactive participants 2014-01-01 480
2013: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 447
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 480
Total of all active and inactive participants 2013-01-01 480
2012: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 456
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 447
Total of all active and inactive participants 2012-01-01 447
2011: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 471
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 456
Total of all active and inactive participants 2011-01-01 456
2010: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 463
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 471
Total of all active and inactive participants 2010-01-01 471
2009: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 448
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 463
Number of retired or separated participants receiving benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 463

Measure	Date	Value
2022: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	448
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	455
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	455
2021: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	455
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	434
Number of retired or separated participants receiving benefits	2021-01-01	6
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	440
2020: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	459
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	454
Number of retired or separated participants receiving benefits	2020-01-01	4
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	458
2019: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	479
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	459
Total of all active and inactive participants	2019-01-01	459
2018: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	489
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	479
Total of all active and inactive participants	2018-01-01	479
2017: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	496
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	489
Total of all active and inactive participants	2017-01-01	489
2016: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	464
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	496
Total of all active and inactive participants	2016-01-01	496
2015: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	480
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	464
Total of all active and inactive participants	2015-01-01	464
2014: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	480
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	480
Total of all active and inactive participants	2014-01-01	480
2013: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	447
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	480
Total of all active and inactive participants	2013-01-01	480
2012: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	456
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	447
Total of all active and inactive participants	2012-01-01	447
2011: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	471
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	456
Total of all active and inactive participants	2011-01-01	456
2010: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	463
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	471
Total of all active and inactive participants	2010-01-01	471
2009: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	448
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	463
Number of retired or separated participants receiving benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	463

Form 5500 Responses for JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN

2022: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE 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 benefit arrangement – Insurance	Yes
2014: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE 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 benefit arrangement – Insurance	Yes
2012: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE 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 benefit arrangement – Insurance	Yes
2011: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE 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 benefit arrangement – Insurance	Yes
2010: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: JEWISH HOME FOR THE ELDERLY MEDICAL INSURANCE 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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

000000468084

Policy instance

Insurance contract or identification number	000000468084
Number of Individuals Covered	94
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $338
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $45,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	338
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )

Policy contract number

1093880002

Policy instance

Insurance contract or identification number	1093880002
Number of Individuals Covered	3
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,417
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $25,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,138
Insurance broker organization code?	3

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

Policy contract number

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	551
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $124,440
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

000000129427

Policy instance

Insurance contract or identification number	000000129427
Number of Individuals Covered	443
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $2,007
Total amount of fees paid to insurance company	USD $167
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 $70,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,007
Amount paid for insurance broker fees	167
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

R0018002

Policy instance

Insurance contract or identification number	R0018002
Number of Individuals Covered	6
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $85
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GCIEE, GRPACCVO
Welfare Benefit Premiums Paid to Carrier	USD $1,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $64
Insurance broker organization code?	3

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

Policy contract number

0007344256

Policy instance

Insurance contract or identification number	0007344256
Number of Individuals Covered	100
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $1,224
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ISWL STND
Welfare Benefit Premiums Paid to Carrier	USD $28,298
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $771
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4942652

Policy instance

Insurance contract or identification number	E4942652
Number of Individuals Covered	110
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,030
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT AND CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $60,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,537
Insurance broker organization code?	3

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

Policy contract number

00580561

Policy instance

Insurance contract or identification number	00580561
Number of Individuals Covered	288
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $15,932
Total amount of fees paid to insurance company	USD $9,134
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $265,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,932
Insurance broker organization code?	3
Amount paid for insurance broker fees	9134
Additional information about fees paid to insurance broker	OTHER

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

1093870000

Policy instance

Insurance contract or identification number	1093870000
Number of Individuals Covered	131
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $55,425
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $969,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,508
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

1093870001

Policy instance

Insurance contract or identification number	1093870001
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $400
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $10,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $321
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

1093870002

Policy instance

Insurance contract or identification number	1093870002
Number of Individuals Covered	273
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $106,740
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $1,822,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $85,715
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

1093870003

Policy instance

Insurance contract or identification number	1093870003
Number of Individuals Covered	4
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $469
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $10,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $377
Insurance broker organization code?	3

HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )

Policy contract number

1093880000

Policy instance

Insurance contract or identification number	1093880000
Number of Individuals Covered	0
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4942652

Policy instance

Insurance contract or identification number	E4942652
Number of Individuals Covered	125
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,028
Total amount of fees paid to insurance company	USD $64
Other welfare benefits provided	ACCIDENT AND CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $71,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,854
Amount paid for insurance broker fees	5
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3

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

Policy contract number

0007344256

Policy instance

Insurance contract or identification number	0007344256
Number of Individuals Covered	105
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $1,391
Total amount of fees paid to insurance company	USD $112
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ISWL STND
Welfare Benefit Premiums Paid to Carrier	USD $31,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $893
Insurance broker organization code?	3
Amount paid for insurance broker fees	112
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID

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

Policy contract number

000000468084

Policy instance

Insurance contract or identification number	000000468084
Number of Individuals Covered	101
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $363
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $48,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	363
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

000000129427

Policy instance

Insurance contract or identification number	000000129427
Number of Individuals Covered	430
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $2,074
Total amount of fees paid to insurance company	USD $174
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 $76,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,074
Amount paid for insurance broker fees	174
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	539
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $169,190
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

00580561

Policy instance

Insurance contract or identification number	00580561
Number of Individuals Covered	287
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $12,717
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $211,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,717
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

1093870000

Policy instance

Insurance contract or identification number	1093870000
Number of Individuals Covered	125
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $18,688
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $817,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,278
Insurance broker organization code?	3

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

Policy contract number

R0018002

Policy instance

Insurance contract or identification number	R0018002
Number of Individuals Covered	7
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $116
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GCIEE, GRPACCVO
Welfare Benefit Premiums Paid to Carrier	USD $1,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $87
Insurance broker organization code?	3

HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )

Policy contract number

1093880002

Policy instance

Insurance contract or identification number	1093880002
Number of Individuals Covered	4
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $753
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $36,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $253
Insurance broker organization code?	3

HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )

Policy contract number

1093880000

Policy instance

Insurance contract or identification number	1093880000
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $161
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $7,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

1093870003

Policy instance

Insurance contract or identification number	1093870003
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $125
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $10,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

1093870002

Policy instance

Insurance contract or identification number	1093870002
Number of Individuals Covered	304
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $39,365
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $1,864,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,224
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

1093870001

Policy instance

Insurance contract or identification number	1093870001
Number of Individuals Covered	5
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $441
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $17,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $148
Insurance broker organization code?	3

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

Policy contract number

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	588
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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	No
Temporary Disability Insurance Welfare Benefit	Yes
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 $153,455
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

000000129427

Policy instance

Insurance contract or identification number	000000129427
Number of Individuals Covered	463
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,857
Total amount of fees paid to insurance company	USD $151
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 $68,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,857
Amount paid for insurance broker fees	151
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

000000468084

Policy instance

Insurance contract or identification number	000000468084
Number of Individuals Covered	111
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $313
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	No
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 $41,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	313
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0913450

Policy instance

Insurance contract or identification number	0913450
Number of Individuals Covered	240
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,764
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 $25,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,764
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0222153

Policy instance

Insurance contract or identification number	0222153
Number of Individuals Covered	492
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $171,194
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 $3,417,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125,759
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

0007344256

Policy instance

Insurance contract or identification number	0007344256
Number of Individuals Covered	120
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,380
Total amount of fees paid to insurance company	USD $149
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	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 $32,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $861
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4942652

Policy instance

Insurance contract or identification number	E4942652
Number of Individuals Covered	146
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $10,312
Total amount of fees paid to insurance company	USD $1,611
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	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT AND CRITICAL ILLNESS
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 $85,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,155
Amount paid for insurance broker fees	222
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3

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

Policy contract number

0007344256

Policy instance

Insurance contract or identification number	0007344256
Number of Individuals Covered	132
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,080
Total amount of fees paid to insurance company	USD $116
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,366
Insurance broker organization code?	3
Amount paid for insurance broker fees	116
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0222153

Policy instance

Insurance contract or identification number	0222153
Number of Individuals Covered	522
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $195,744
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,591,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $143,679
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0913450

Policy instance

Insurance contract or identification number	0913450
Number of Individuals Covered	249
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,835
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,837
Insurance broker organization code?	3

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

Policy contract number

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	581
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $178,273
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

000000468084

Policy instance

Insurance contract or identification number	000000468084
Number of Individuals Covered	117
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $361
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $63,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	361
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

000000129427

Policy instance

Insurance contract or identification number	000000129427
Number of Individuals Covered	457
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,114
Total amount of fees paid to insurance company	USD $178
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 $80,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,114
Amount paid for insurance broker fees	178
Insurance broker organization code?	3

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

Policy contract number

R0018002

Policy instance

Insurance contract or identification number	R0018002
Number of Individuals Covered	13
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $244
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GCIEE, GRPACCVO
Welfare Benefit Premiums Paid to Carrier	USD $3,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $183
Insurance broker organization code?	3

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

Policy contract number

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	500
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $170,421
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

000000129427

Policy instance

Insurance contract or identification number	000000129427
Number of Individuals Covered	496
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,041
Total amount of fees paid to insurance company	USD $170
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 $74,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,041
Amount paid for insurance broker fees	170
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

ANTHEM HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 60217 )

Policy contract number

800803

Policy instance

Insurance contract or identification number	800803
Number of Individuals Covered	0
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $455
Total amount of fees paid to insurance company	USD $0
Vision 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 $455
Insurance broker organization code?	3

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

Policy contract number

000000468084

Policy instance

Insurance contract or identification number	000000468084
Number of Individuals Covered	140
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $342
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $38,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	342
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

JS11991

Policy instance

Insurance contract or identification number	JS11991
Number of Individuals Covered	500
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $119,795
Total amount of fees paid to insurance company	USD $46,267
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,631,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $119,795
Insurance broker organization code?	3
Amount paid for insurance broker fees	46267
Additional information about fees paid to insurance broker	BONUS

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0913450

Policy instance

Insurance contract or identification number	0913450
Number of Individuals Covered	257
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,113
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,835
Insurance broker organization code?	3

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

Policy contract number

R0018002

Policy instance

Insurance contract or identification number	R0018002
Number of Individuals Covered	6
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,855
Total amount of fees paid to insurance company	USD $139
Other welfare benefits provided	CRITICAL ILLNESS AND ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $20,342
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,141
Amount paid for insurance broker fees	139
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

04672

Policy instance

Insurance contract or identification number	04672
Number of Individuals Covered	326
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $13,058
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $241,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,058
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

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

Policy contract number

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	496
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $167,556
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

000000129427

Policy instance

Insurance contract or identification number	000000129427
Number of Individuals Covered	492
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,022
Total amount of fees paid to insurance company	USD $168
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 $73,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,022
Amount paid for insurance broker fees	168
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

ANTHEM HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 60217 )

Policy contract number

G1800

Policy instance

Insurance contract or identification number	G1800
Number of Individuals Covered	248
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,724
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,724
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

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

Policy contract number

000000468084

Policy instance

Insurance contract or identification number	000000468084
Number of Individuals Covered	150
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $323
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $43,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	323
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

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

Policy contract number

000000129427

Policy instance

Insurance contract or identification number	000000129427
Number of Individuals Covered	468
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,908
Total amount of fees paid to insurance company	USD $414
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,908
Amount paid for insurance broker fees	414
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

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

Policy contract number

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	617
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $154,429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

4672

Policy instance

Insurance contract or identification number	4672
Number of Individuals Covered	307
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $11,642
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $292,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,642
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

MEDICAL INNOVATIVE HEALTHPLANS (National Association of Insurance Commissioners NAIC id number: 78026 )

Policy contract number

501

Policy instance

Insurance contract or identification number	501
Number of Individuals Covered	322
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,521,865
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

000000468084

Policy instance

Insurance contract or identification number	000000468084
Number of Individuals Covered	164
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 $729
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	729
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

ANTHEM HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 60217 )

Policy contract number

G1800

Policy instance

Insurance contract or identification number	G1800
Number of Individuals Covered	221
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,698
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,698
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

ANTHEM HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 60217 )

Policy contract number

G1800

Policy instance

Insurance contract or identification number	G1800
Number of Individuals Covered	232
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,667
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 $27,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,667
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

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

Policy contract number

129427

Policy instance

Insurance contract or identification number	129427
Number of Individuals Covered	208
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,479
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

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	635
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $172,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

4672

Policy instance

Insurance contract or identification number	4672
Number of Individuals Covered	340
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $13,481
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 $307,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,481
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

303177

Policy instance

Insurance contract or identification number	303177
Number of Individuals Covered	476
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $68,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICAL INNOVATIVE HEALTHPLANS (National Association of Insurance Commissioners NAIC id number: 78026 )

Policy contract number

501

Policy instance

Insurance contract or identification number	501
Number of Individuals Covered	330
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $39,120
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 $3,487,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

4672

Policy instance

Insurance contract or identification number	4672
Number of Individuals Covered	348
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $13,243
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 $261,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,243
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

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

Policy contract number

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	636
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $164,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

303177

Policy instance

Insurance contract or identification number	303177
Number of Individuals Covered	478
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $65,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 60217 )

Policy contract number

G1800

Policy instance

Insurance contract or identification number	G1800
Number of Individuals Covered	219
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,537
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 $23,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,155
Insurance broker organization code?	3
Insurance broker name	THE NIA/UIA GROUP, LLC

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

Policy contract number

129427

Policy instance

Insurance contract or identification number	129427
Number of Individuals Covered	211
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,337
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

JH5007

Policy instance

Insurance contract or identification number	JH5007
Number of Individuals Covered	620
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,327,680
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

JH5007

Policy instance

Insurance contract or identification number	JH5007
Number of Individuals Covered	624
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,243,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

303177

Policy instance

Insurance contract or identification number	303177
Number of Individuals Covered	447
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $61,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

4672

Policy instance

Insurance contract or identification number	4672
Number of Individuals Covered	332
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $13,312
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $268,238
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,312
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

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

Policy contract number

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	572
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $159,468
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

129427

Policy instance

Insurance contract or identification number	129427
Number of Individuals Covered	186
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

86861

Policy instance

Insurance contract or identification number	86861
Number of Individuals Covered	455
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
Other welfare benefits provided	BASIC AD & D
Welfare Benefit Premiums Paid to Carrier	USD $3,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

86861

Policy instance

Insurance contract or identification number	86861
Number of Individuals Covered	156
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

86861

Policy instance

Insurance contract or identification number	86861
Number of Individuals Covered	156
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
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $2,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

86861

Policy instance

Insurance contract or identification number	86861
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

86861

Policy instance

Insurance contract or identification number	86861
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $646
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

129427

Policy instance

Insurance contract or identification number	129427
Number of Individuals Covered	197
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,748
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

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	591
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $165,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

86861

Policy instance

Insurance contract or identification number	86861
Number of Individuals Covered	455
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

4672

Policy instance

Insurance contract or identification number	4672
Number of Individuals Covered	335
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $13,929
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 $271,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

86861

Policy instance

Insurance contract or identification number	86861
Number of Individuals Covered	455
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,227
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

JH5007

Policy instance

Insurance contract or identification number	JH5007
Number of Individuals Covered	610
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,655,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

86861

Policy instance

Insurance contract or identification number	86861
Number of Individuals Covered	469
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )

Policy contract number

4672

Policy instance

Insurance contract or identification number	4672
Number of Individuals Covered	348
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $16,100
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 $280,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,100
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

86861

Policy instance

Insurance contract or identification number	86861
Number of Individuals Covered	469
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,249
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

000000129426

Policy instance

Insurance contract or identification number	000000129426
Number of Individuals Covered	614
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $179,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

86861

Policy instance

Insurance contract or identification number	86861
Number of Individuals Covered	469
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
Other welfare benefits provided	BASIC AD & D
Welfare Benefit Premiums Paid to Carrier	USD $3,317
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

JH5007

Policy instance

Insurance contract or identification number	JH5007
Number of Individuals Covered	631
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,035,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	THE JEWISH HOME FOR THE ELDERLY
Employer identification number (EIN):	060846991
NAIC Classification:	813000
NAIC Description:	Religious, Grantmaking, Civic, Professional, and Similar Organizations

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	ROGER SLIBY	2023-10-11
501	2021-01-01	ROGER SLIBY	2023-07-12
501	2020-01-01
501	2019-01-01	ROGER SILBY	2020-09-03
501	2018-01-01	ROGER SLIBY	2019-09-26
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	ANDREW H. BANOFF
501	2011-01-01	LINDA CISZKOWSKI
501	2010-01-01	LINDA CISZKOWSKI
501	2009-01-01	LINDA C CISZKOWSKI