401k Plan data: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN plan

OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 401k Plan overview

Plan Name	OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN
Plan identification number	501

OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN Benefits

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

401k Sponsoring company profile

OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS has sponsored the creation of one or more 401k plans.

Company Name: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS

Employer identification number (EIN): 061280188

NAIC Classification: 334110

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-01-01 BETSY BATTER LAURA DEMPSEY 2017-10-11
501 2015-01-01 BETSY BATTER
501 2014-01-01 GREGG BARNES GREGG BARNES 2015-07-01
501 2013-01-01 GREGG BARNES GREGG BARNES 2014-10-28
501 2012-01-01 GREGG BARNES
501 2011-01-01 GREGG BARNES
501 2010-01-01 JOHN PAYNE JOHN PAYNE 2011-06-28
501 2009-01-01 CINDY LYMAN

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2016-01-01	BETSY BATTER	LAURA DEMPSEY	2017-10-11
501	2015-01-01	BETSY BATTER
501	2014-01-01	GREGG BARNES	GREGG BARNES	2015-07-01
501	2013-01-01	GREGG BARNES	GREGG BARNES	2014-10-28
501	2012-01-01	GREGG BARNES
501	2011-01-01	GREGG BARNES
501	2010-01-01	JOHN PAYNE	JOHN PAYNE	2011-06-28
501	2009-01-01	CINDY LYMAN

Plan Statistics for OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN

401k plan membership statisitcs for OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN

Measure Date Value
2016: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 390
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
2015: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 556
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 563
Number of retired or separated participants receiving benefits 2015-01-01 8
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 571
2014: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 535
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 549
Total of all active and inactive participants 2014-01-01 549
2013: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 581
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 535
Total of all active and inactive participants 2013-01-01 535
2012: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 549
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 581
Total of all active and inactive participants 2012-01-01 581
Total participants 2012-01-01 581
2011: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 492
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 533
Number of retired or separated participants receiving benefits 2011-01-01 16
Total of all active and inactive participants 2011-01-01 549
Total participants 2011-01-01 549
2010: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 409
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 492
Number of retired or separated participants receiving benefits 2010-01-01 9
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 501
2009: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 407
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 405
Number of retired or separated participants receiving benefits 2009-01-01 4
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 409

Measure	Date	Value
2016: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	390
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
2015: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	556
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	563
Number of retired or separated participants receiving benefits	2015-01-01	8
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	571
2014: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	535
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	549
Total of all active and inactive participants	2014-01-01	549
2013: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	581
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	535
Total of all active and inactive participants	2013-01-01	535
2012: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	549
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	581
Total of all active and inactive participants	2012-01-01	581
Total participants	2012-01-01	581
2011: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	492
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	533
Number of retired or separated participants receiving benefits	2011-01-01	16
Total of all active and inactive participants	2011-01-01	549
Total participants	2011-01-01	549
2010: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	409
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	492
Number of retired or separated participants receiving benefits	2010-01-01	9
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	501
2009: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	407
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	405
Number of retired or separated participants receiving benefits	2009-01-01	4
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	409

Form 5500 Responses for OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN

2016: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	Yes
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS GROUP BENEFITS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47093 )

Policy contract number

30001292

Policy instance

Insurance contract or identification number	30001292
Number of Individuals Covered	369
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,851
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $49,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $971
Insurance broker organization code?	3
Insurance broker name	DIGITAL INSURANCE INC.

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

Policy contract number

LK963670

Policy instance

Insurance contract or identification number	LK963670
Number of Individuals Covered	563
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,940
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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	Yes
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 $93,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,532
Insurance broker organization code?	3
Insurance broker name	WILLIS OF PENNSYLVANIA INC.

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

Policy contract number

ABL960604

Policy instance

Insurance contract or identification number	ABL960604
Number of Individuals Covered	563
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,433
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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	ACCIDENTAL DEATH
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 $9,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,433
Insurance broker organization code?	3
Insurance broker name	DIGITAL INSURANCE INC.

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

Policy contract number

OK966862

Policy instance

Insurance contract or identification number	OK966862
Number of Individuals Covered	563
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,275
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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	ACCIDENTAL DEATH
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 $25,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,573
Insurance broker organization code?	3
Insurance broker name	WILLIS OF PENNSYLVANIA INC.

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

Policy contract number

FLI960191

Policy instance

Insurance contract or identification number	FLI960191
Number of Individuals Covered	563
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,201
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $140,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,843
Insurance broker organization code?	3
Insurance broker name	WILLIS OF PENNSYLVANIA INC.

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

Policy contract number

LK751335

Policy instance

Insurance contract or identification number	LK751335
Number of Individuals Covered	563
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,195
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $148,991
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,806
Insurance broker organization code?	3
Insurance broker name	WILLIS OF PENNSYLVANIA INC.

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

Policy contract number

Policy instance

Number of Individuals Covered	1112
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $16,012
Total amount of fees paid to insurance company	USD $99,752
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,012
Amount paid for insurance broker fees	99752
Additional information about fees paid to insurance broker	ADMINSITRATIVE FEE
Insurance broker organization code?	3
Insurance broker name	MCSWEENEY & RICCI INS AGENCY INC.

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

Policy contract number

LK 751335

Policy instance

Insurance contract or identification number	LK 751335
Number of Individuals Covered	549
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,095
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	SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $129,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,095
Insurance broker organization code?	3
Insurance broker name	DIGITAL INSURANCE INC

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

Policy contract number

LK 963670

Policy instance

Insurance contract or identification number	LK 963670
Number of Individuals Covered	549
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,723
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 $72,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,723
Insurance broker name	DIGITAL INSURANCE INC

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

Policy contract number

FLI960191

Policy instance

Insurance contract or identification number	FLI960191
Number of Individuals Covered	549
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $4,037
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 $107,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,037
Insurance broker organization code?	3
Insurance broker name	DIGITAL INSURANCE INC

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

Policy contract number

ABL960604

Policy instance

Insurance contract or identification number	ABL960604
Number of Individuals Covered	549
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $1,731
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $11,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,731
Insurance broker organization code?	3
Insurance broker name	DIGITAL INSURANCE INC

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

Policy instance

Number of Individuals Covered	461
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	SPECIFIC EXCESS LOSS INDEMNITY
Welfare Benefit Premiums Paid to Carrier	USD $363,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

OK 966862

Policy instance

Insurance contract or identification number	OK 966862
Number of Individuals Covered	549
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $1,625
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $16,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,625
Insurance broker organization code?	3
Insurance broker name	DIGITAL INSURANCE INC

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

Policy contract number

001NB6

Policy instance

Insurance contract or identification number	001NB6
Number of Individuals Covered	451
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 $288,997
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 $363,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	193832
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker name	HEALTH PLANS INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47093 )

Policy contract number

30001292

Policy instance

Insurance contract or identification number	30001292
Number of Individuals Covered	366
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,567
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 $49,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,567
Insurance broker organization code?	3
Insurance broker name	MCSWEENEY & RICCI INS AGENCY INC.

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

Policy contract number

ABL960604

Policy instance

Insurance contract or identification number	ABL960604
Number of Individuals Covered	535
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $1,731
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $11,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,731
Insurance broker name	MCSWEENEY & RICCI INS AGENCY INC.

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

Policy contract number

001NB6

Policy instance

Insurance contract or identification number	001NB6
Number of Individuals Covered	481
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 $305,323
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 $382,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	131836
Additional information about fees paid to insurance broker	MEDICAL/COBRA/HIPAA ADMINISTRATION
Insurance broker name	HEALTH PLANS INC.

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

Policy contract number

Policy instance

Number of Individuals Covered	1143
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $21,583
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,583
Additional information about fees paid to insurance broker	ADMINISTRATION FEES
Insurance broker name	MCSWEENEY & RICCI INS AGENCY INC.

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

Policy contract number

LK 751335

Policy instance

Insurance contract or identification number	LK 751335
Number of Individuals Covered	535
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,097
Total amount of fees paid to insurance company	USD $2,465
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	SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $129,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,097
Amount paid for insurance broker fees	2465
Insurance broker name	MCSWEENEY & RICCI INS AGENCY INC.

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

Policy contract number

LK 963670

Policy instance

Insurance contract or identification number	LK 963670
Number of Individuals Covered	535
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,724
Total amount of fees paid to insurance company	USD $1,893
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 $72,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,724
Amount paid for insurance broker fees	1893
Insurance broker name	MCSWEENEY & RICCI INS AGENCY INC.

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

Policy contract number

FLI960191

Policy instance

Insurance contract or identification number	FLI960191
Number of Individuals Covered	535
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $4,058
Total amount of fees paid to insurance company	USD $1,924
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 $111,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,058
Amount paid for insurance broker fees	1924
Insurance broker name	MCSWEENEY & RICCI INS AGENCY INC.

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

Policy contract number

OK 966862

Policy instance

Insurance contract or identification number	OK 966862
Number of Individuals Covered	535
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $1,718
Total amount of fees paid to insurance company	USD $350
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $17,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,718
Amount paid for insurance broker fees	350
Insurance broker name	MCSWEENEY & RICCI INS AGENCY INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47093 )

Policy contract number

30001292

Policy instance

Insurance contract or identification number	30001292
Number of Individuals Covered	356
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,852
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,298
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,852
Insurance broker name	MCSWEENEY & RICCI INS AGENCY INC.

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

Policy instance

Number of Individuals Covered	452
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
Other welfare benefits provided	SPECIFIC EXCESS LOSS INDEMNITY
Welfare Benefit Premiums Paid to Carrier	USD $383,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47093 )

Policy contract number

30001292

Policy instance

Insurance contract or identification number	30001292
Number of Individuals Covered	357
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,786
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,453
Commission paid to Insurance Broker	USD $1,786
Insurance broker organization code?	3
Insurance broker name	MCSWEENEY & RICCI INSURANCE AGENCY

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

Policy contract number

002118

Policy instance

Insurance contract or identification number	002118
Number of Individuals Covered	1188
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $21,544
Dental Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $21,544
Insurance broker organization code?	3
Insurance broker name	MCSWEENEY & RICCI INS AGENCY INC.

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

Policy contract number

ABL960604

Policy instance

Insurance contract or identification number	ABL960604
Number of Individuals Covered	581
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $1,881
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $12,538
Commission paid to Insurance Broker	USD $150
Insurance broker organization code?	3
Insurance broker name	MCSWEENEY & RICCI AGENCY

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

00400001000 123

Policy instance

Insurance contract or identification number	00400001000 123
Number of Individuals Covered	262
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,923
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $66,441
Commission paid to Insurance Broker	USD $6,644
Insurance broker organization code?	3
Insurance broker name	WM GALLAGHER ASSOC INS BROKERS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010134749

Policy instance

Insurance contract or identification number	000010134749
Number of Individuals Covered	581
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,157
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $109,575
Commission paid to Insurance Broker	USD $3,882
Insurance broker organization code?	3
Insurance broker name	WM GALLAGHER ASSOC INS BROKERS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010134748

Policy instance

Insurance contract or identification number	000010134748
Number of Individuals Covered	581
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,191
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $63,355
Commission paid to Insurance Broker	USD $4,754
Insurance broker organization code?	3
Insurance broker name	WM GALLAGHER ASSOC INS BROKERS

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

MLB000015-12

Policy instance

Insurance contract or identification number	MLB000015-12
Number of Individuals Covered	495
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Welfare Benefit Premiums Paid to Carrier	USD $432,415

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010134747

Policy instance

Insurance contract or identification number	000010134747
Number of Individuals Covered	581
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,881
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D D
Welfare Benefit Premiums Paid to Carrier	USD $63,563
Commission paid to Insurance Broker	USD $3,256
Insurance broker organization code?	3
Insurance broker name	WM GALLAGHER ASSOC INS BROKERS

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

Policy contract number

001NB6

Policy instance

Insurance contract or identification number	001NB6
Number of Individuals Covered	1084
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of fees paid to insurance company	USD $315,942
Health Insurance Welfare Benefit	Yes
Amount paid for insurance broker fees	76134
Additional information about fees paid to insurance broker	ADMINISTRATION - BROKER
Insurance broker name	HEALTH PLANS, INC.

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

Policy contract number

002118

Policy instance

Insurance contract or identification number	002118
Number of Individuals Covered	1155
Insurance policy start date	2011-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $34,111
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010134747

Policy instance

Insurance contract or identification number	000010134747
Number of Individuals Covered	544
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,300
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D D
Welfare Benefit Premiums Paid to Carrier	USD $72,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010134748

Policy instance

Insurance contract or identification number	000010134748
Number of Individuals Covered	544
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,714
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $63,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ABL960604

Policy instance

Insurance contract or identification number	ABL960604
Number of Individuals Covered	533
Insurance policy start date	2011-01-01
Insurance policy end date	2012-01-01
Total amount of commissions paid to insurance broker	USD $2,165
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $14,436

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010134749

Policy instance

Insurance contract or identification number	000010134749
Number of Individuals Covered	544
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,725
Unemployment Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

00400001000 123

Policy instance

Insurance contract or identification number	00400001000 123
Number of Individuals Covered	130
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,684
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $56,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47093 )

Policy contract number

30001292

Policy instance

Insurance contract or identification number	30001292
Number of Individuals Covered	354
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,728
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

4954102

Policy instance

Insurance contract or identification number	4954102
Number of Individuals Covered	1069
Insurance policy start date	2011-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $77,918
Total amount of fees paid to insurance company	USD $36,800
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47093 )

Policy contract number

30001292

Policy instance

Insurance contract or identification number	30001292
Number of Individuals Covered	289
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $358
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $27,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $358
Insurance broker organization code?	3
Insurance broker name	WILLIAM GALLAGHER ASSOCIATES

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

H54200

Policy instance

Insurance contract or identification number	H54200
Number of Individuals Covered	492
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $17,669
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
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 $247,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,676
Insurance broker organization code?	3
Insurance broker name	WILLIAM GALLAGHER ASSOCIATES

NATIONAL VISION ADMINISTRATORS, LLC (National Association of Insurance Commissioners NAIC id number: 66842 )

Policy contract number

00505370

Policy instance

Insurance contract or identification number	00505370
Number of Individuals Covered	18
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $53
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53
Insurance broker organization code?	3
Insurance broker name	THERESA COEN

KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 )

Policy contract number

00505370

Policy instance

Insurance contract or identification number	00505370
Number of Individuals Covered	5
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,632
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $42,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,632
Insurance broker organization code?	3
Insurance broker name	THERESA COEN

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

Policy contract number

ABL960604

Policy instance

Insurance contract or identification number	ABL960604
Number of Individuals Covered	492
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,165
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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	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 $14,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,165
Insurance broker organization code?	3
Insurance broker name	PARADIGM INSURANCE AGENCY

CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 )

Policy contract number

00505370

Policy instance

Insurance contract or identification number	00505370
Number of Individuals Covered	18
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,480
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $135,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,480
Insurance broker organization code?	3
Insurance broker name	THERESA COEN

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

Policy contract number

4954102

Policy instance

Insurance contract or identification number	4954102
Number of Individuals Covered	908
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $63,568
Total amount of fees paid to insurance company	USD $19,134
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,278
Amount paid for insurance broker fees	19134
Additional information about fees paid to insurance broker	BONUS AND PERSISTENCY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	WILLIAM GALLAGHER ASSOCIATES

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

Policy contract number

002118

Policy instance

Insurance contract or identification number	002118
Number of Individuals Covered	886
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $22,991
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,830
Insurance broker organization code?	3
Insurance broker name	WILLIAM GALLAGHER ASSOCIATES

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Company Name:	OLYMPUS SCIENTIFIC SOLUTIONS AMERICAS
Employer identification number (EIN):	061280188
NAIC Classification:	334110