LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN
Plan identification number	501

LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN Benefits

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

401k Sponsoring company profile

LEVITON MANUFACTURING CO., INC. has sponsored the creation of one or more 401k plans.

Company Name:	LEVITON MANUFACTURING CO., INC.
Employer identification number (EIN):	111001790
NAIC Classification:	335900

Additional information about LEVITON MANUFACTURING CO., INC.

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	1994-05-06
Company Identification Number:	0009990906
Legal Registered Office Address:	201 N SERVICE RD MELVILLE United States of America (USA) 11747

More information about LEVITON MANUFACTURING CO., INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	LUCY GUILHERME		MARK BAYDARIAN	2018-10-09
501	2016-01-01	LUCY GUILHERME		MARK BAYDARIAN	2017-07-17
501	2015-01-01	LUCY GUILHERME		MARK BAYDARIAN	2016-09-13
501	2014-01-01	LUCY GUILHERME		MARK BAYDARIAN	2015-10-14
501	2013-01-01	LUCY GUILHERME		MARK BAYDARIAN	2014-08-21
501	2012-01-01	LUCY GUILHERME		MARK BAYDARIAN	2013-10-08
501	2011-01-01	LUCY GUILHERME		MARK BAYDARIAN	2012-09-21
501	2010-01-01	LUCY GUILHERME		MARK BAYDARIAN	2011-10-07
501	2009-01-01	LUCY GUILHERME		TUAN DANG	2010-10-12

Plan Statistics for LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN

401k plan membership statisitcs for LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN

Measure	Date	Value
2022: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	2,426
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	1,942
Number of retired or separated participants receiving benefits	2022-01-01	542
Total of all active and inactive participants	2022-01-01	2,484
2021: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	2,483
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	1,884
Number of retired or separated participants receiving benefits	2021-01-01	542
Total of all active and inactive participants	2021-01-01	2,426
2020: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	4,732
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	3,988
Number of retired or separated participants receiving benefits	2020-01-01	493
Total of all active and inactive participants	2020-01-01	4,481
2019: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	3,058
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	4,131
Number of retired or separated participants receiving benefits	2019-01-01	601
Total of all active and inactive participants	2019-01-01	4,732
2018: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	2,792
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	2,314
Number of retired or separated participants receiving benefits	2018-01-01	601
Total of all active and inactive participants	2018-01-01	2,915
2017: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	2,675
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	2,140
Number of retired or separated participants receiving benefits	2017-01-01	652
Total of all active and inactive participants	2017-01-01	2,792
2016: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	2,658
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,997
Number of retired or separated participants receiving benefits	2016-01-01	701
Total of all active and inactive participants	2016-01-01	2,698
2015: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	2,668
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,979
Number of retired or separated participants receiving benefits	2015-01-01	709
Total of all active and inactive participants	2015-01-01	2,688
2014: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	2,692
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,873
Number of retired or separated participants receiving benefits	2014-01-01	808
Total of all active and inactive participants	2014-01-01	2,681
2013: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	2,849
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,878
Number of retired or separated participants receiving benefits	2013-01-01	814
Total of all active and inactive participants	2013-01-01	2,692
2012: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	2,887
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	2,094
Number of retired or separated participants receiving benefits	2012-01-01	755
Total of all active and inactive participants	2012-01-01	2,849
2011: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	3,149
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	2,118
Number of retired or separated participants receiving benefits	2011-01-01	769
Total of all active and inactive participants	2011-01-01	2,887
2010: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	3,576
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	2,416
Number of retired or separated participants receiving benefits	2010-01-01	733
Total of all active and inactive participants	2010-01-01	3,149
2009: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	3,889
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	2,697
Number of retired or separated participants receiving benefits	2009-01-01	879
Total of all active and inactive participants	2009-01-01	3,576

Form 5500 Responses for LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN

2022: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan is a collectively bargained plan	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan is a collectively bargained plan	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan is a collectively bargained plan	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan is a collectively bargained plan	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan is a collectively bargained plan	Yes
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan is a collectively bargained plan	Yes
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan is a collectively bargained plan	Yes
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan is a collectively bargained plan	Yes
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: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan is a collectively bargained plan	Yes
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: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan is a collectively bargained plan	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: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan is a collectively bargained plan	Yes
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: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan is a collectively bargained plan	Yes
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: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan is a collectively bargained plan	Yes
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: LEVITON MANUFACTURING CO., INC. HEALTH & WELFARE 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 is a collectively bargained plan	Yes
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

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	2
Insurance contract or identification number 702404 Number of Individuals Covered 486 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $3,810 Total amount of fees paid to insurance company USD $4,773 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $116,880 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,810 Amount paid for insurance broker fees 4773 Additional information about fees paid to insurance broker 2021 PINNACLE DENTAL RETENTION INCENTIVE RISK
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	14163768-9001
Policy instance	1
Insurance contract or identification number 14163768-9001 Number of Individuals Covered 3118 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $40,830 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $40,830 Insurance broker organization code? 3
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	001530
Policy instance	3
Insurance contract or identification number 001530 Number of Individuals Covered 3691 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $5,847 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,847 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0211058
Policy instance	4
Insurance contract or identification number 0211058 Number of Individuals Covered 3812 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $129,821 Total amount of fees paid to insurance company USD $28,584 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $1,937,479 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $129,821 Amount paid for insurance broker fees 28584 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION AND MARKETING FEES Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0212392
Policy instance	5
Insurance contract or identification number 0212392 Number of Individuals Covered 423 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 $506 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $147,960 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 506 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	10079941001/100
Policy instance	6
Insurance contract or identification number 10079941001/100 Number of Individuals Covered 2461 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $7,284 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $143,335 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,284 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	04058C
Policy instance	7
Insurance contract or identification number 04058C 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 $1,638 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $17,636 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,638 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	04058C
Policy instance	8
Insurance contract or identification number 04058C 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 $4,935 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Other welfare benefits provided EVACUATION COVERAGE Welfare Benefit Premiums Paid to Carrier USD $52,908 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,935 Insurance broker organization code? 3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	10079951001
Policy instance	12
Insurance contract or identification number 10079951001 Number of Individuals Covered 17 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $69 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,288 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $69 Insurance broker organization code? 3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract number	1815710A
Policy instance	11
Insurance contract or identification number 1815710A Number of Individuals Covered 1978 Insurance policy start date 2022-03-12 Insurance policy end date 2023-03-12 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0223149
Policy instance	10
Insurance contract or identification number 0223149 Number of Individuals Covered 1982 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $21,945 Total amount of fees paid to insurance company USD $3,102 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $173,810 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,945 Amount paid for insurance broker fees 3102 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION AND MARKETING FEES Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0223206
Policy instance	9
Insurance contract or identification number 0223206 Number of Individuals Covered 1416 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $43,417 Total amount of fees paid to insurance company USD $5,333 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $311,379 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $43,417 Amount paid for insurance broker fees 5333 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION AND MARKETING FEES
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	14163768-9001
Policy instance	1
Insurance contract or identification number 14163768-9001 Number of Individuals Covered 3187 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $42,224 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $42,224 Insurance broker organization code? 3
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	001530
Policy instance	3
Insurance contract or identification number 001530 Number of Individuals Covered 3707 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $5,959 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,959 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0211058
Policy instance	4
Insurance contract or identification number 0211058 Number of Individuals Covered 8200 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $153,825 Total amount of fees paid to insurance company USD $41,836 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $1,925,074 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $153,825 Amount paid for insurance broker fees 41836 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION AND MARKETING FEES Insurance broker organization code? 3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	10079941001/100
Policy instance	6
Insurance contract or identification number 10079941001/100 Number of Individuals Covered 2385 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $7,475 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $146,196 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,475 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0212392
Policy instance	5
Insurance contract or identification number 0212392 Number of Individuals Covered 438 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 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 $149,370 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	04058B
Policy instance	7
Insurance contract or identification number 04058B Number of Individuals Covered 2 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $564 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $5,638 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $564 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	04058B
Policy instance	8
Insurance contract or identification number 04058B Number of Individuals Covered 2 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $2,113 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Other welfare benefits provided EVACUATION COVERAGE Welfare Benefit Premiums Paid to Carrier USD $21,126 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,113 Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	2
Insurance contract or identification number 702404 Number of Individuals Covered 483 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $3,205 Total amount of fees paid to insurance company USD $625 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $114,973 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,205 Amount paid for insurance broker fees 625 Additional information about fees paid to insurance broker 2020 PINNCACLE SPECIALTY RETENTION INCENTIVE RISK Insurance broker organization code? 3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract number	ADDN1815710A
Policy instance	11
Insurance contract or identification number ADDN1815710A Number of Individuals Covered 1935 Insurance policy start date 2021-03-12 Insurance policy end date 2022-03-12 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT 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 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0223149
Policy instance	10
Insurance contract or identification number 0223149 Number of Individuals Covered 1908 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $31,657 Total amount of fees paid to insurance company USD $2,776 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $173,447 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $31,657 Amount paid for insurance broker fees 2776 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION & MARKETING Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0223206
Policy instance	9
Insurance contract or identification number 0223206 Number of Individuals Covered 1380 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $70,196 Total amount of fees paid to insurance company USD $4,848 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $267,155 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $70,196 Amount paid for insurance broker fees 4848 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION AND MARKETING Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	009336
Policy instance	1
Insurance contract or identification number 009336 Number of Individuals Covered 1 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $25 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $25 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008627
Policy instance	2
Insurance contract or identification number 008627 Number of Individuals Covered 2208 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $19,390 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $19,390 Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	4
Insurance contract or identification number 702404 Number of Individuals Covered 498 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $4,260 Total amount of fees paid to insurance company USD $5,835 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $124,102 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,260 Amount paid for insurance broker fees 5835 Additional information about fees paid to insurance broker 2019 PPP SPECIALTY RETENTION RISK Insurance broker organization code? 3
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	001530
Policy instance	5
Insurance contract or identification number 001530 Number of Individuals Covered 3368 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $5,234 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,234 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	011610
Policy instance	3
Insurance contract or identification number 011610 Number of Individuals Covered 1088 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 $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0211058
Policy instance	6
Insurance contract or identification number 0211058 Number of Individuals Covered 3988 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $110,868 Total amount of fees paid to insurance company USD $22,437 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $1,769,545 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $110,868 Amount paid for insurance broker fees 22437 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0212392
Policy instance	7
Insurance contract or identification number 0212392 Number of Individuals Covered 445 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 $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $78,693 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	04058B
Policy instance	11
Insurance contract or identification number 04058B Number of Individuals Covered 2 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $4,202 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Other welfare benefits provided EVACUATION COVERAGE Welfare Benefit Premiums Paid to Carrier USD $42,017 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,202 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 78697 )
Policy contract number	10079941001
Policy instance	8
Insurance contract or identification number 10079941001 Number of Individuals Covered 2469 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $7,562 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $147,998 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,562 Insurance broker organization code? 3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract number	ADDN1815710A
Policy instance	9
Insurance contract or identification number ADDN1815710A Number of Individuals Covered 1903 Insurance policy start date 2020-03-12 Insurance policy end date 2021-03-12 Total amount of commissions paid to insurance broker USD $7,412 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $49,410 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,412 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	04058B
Policy instance	10
Insurance contract or identification number 04058B Number of Individuals Covered 2 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,128 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $11,276 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,128 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008627
Policy instance	2
Insurance contract or identification number 008627 Number of Individuals Covered 2367 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $23,020 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $23,020 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	011610
Policy instance	3
Insurance contract or identification number 011610 Number of Individuals Covered 1096 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $10,385 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $10,385 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	04058B
Policy instance	11
Insurance contract or identification number 04058B Number of Individuals Covered 2 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $4,107 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Other welfare benefits provided EVACUATION COVERAGE Welfare Benefit Premiums Paid to Carrier USD $41,073 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,107 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	009336
Policy instance	1
Insurance contract or identification number 009336 Number of Individuals Covered 1 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $64 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $64 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	04058B
Policy instance	10
Insurance contract or identification number 04058B Number of Individuals Covered 2 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,128 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $11,276 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,128 Insurance broker organization code? 3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	64096482
Policy instance	9
Insurance contract or identification number 64096482 Number of Individuals Covered 1903 Insurance policy start date 2019-03-12 Insurance policy end date 2020-03-12 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT 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 Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	4
Insurance contract or identification number 702404 Number of Individuals Covered 512 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $4,166 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $154,372 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,166 Insurance broker organization code? 3
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	001530
Policy instance	5
Insurance contract or identification number 001530 Number of Individuals Covered 3421 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $5,371 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,371 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0211058
Policy instance	6
Insurance contract or identification number 0211058 Number of Individuals Covered 4131 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $121,051 Total amount of fees paid to insurance company USD $23,176 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $1,372,569 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $121,051 Amount paid for insurance broker fees 23176 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0212392
Policy instance	7
Insurance contract or identification number 0212392 Number of Individuals Covered 443 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 $34,539 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 78697 )
Policy contract number	10079941001
Policy instance	8
Insurance contract or identification number 10079941001 Number of Individuals Covered 2515 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $8,889 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $153,190 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,889 Insurance broker organization code? 3
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	001530
Policy instance	5
Insurance contract or identification number 001530 Number of Individuals Covered 3769 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $5,357 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,357 Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	4
Insurance contract or identification number 702404 Number of Individuals Covered 442 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $3,682 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $129,895 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,682 Insurance broker organization code? 3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	011610
Policy instance	3
Insurance contract or identification number 011610 Number of Individuals Covered 1046 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $10,892 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $10,892 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 78697 )
Policy contract number	10079941001
Policy instance	8
Insurance contract or identification number 10079941001 Number of Individuals Covered 2226 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $7,567 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $159,245 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,567 Insurance broker organization code? 3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	64096482
Policy instance	9
Insurance contract or identification number 64096482 Number of Individuals Covered 1867 Insurance policy start date 2018-03-12 Insurance policy end date 2019-03-12 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	009336
Policy instance	1
Insurance contract or identification number 009336 Number of Individuals Covered 6 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $157 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $157 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0211058
Policy instance	6
Insurance contract or identification number 0211058 Number of Individuals Covered 4208 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $86,123 Total amount of fees paid to insurance company USD $23,296 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $1,537,050 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $86,123 Amount paid for insurance broker fees 23296 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0212392
Policy instance	7
Insurance contract or identification number 0212392 Number of Individuals Covered 448 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 $34,400 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008627
Policy instance	2
Insurance contract or identification number 008627 Number of Individuals Covered 2524 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $31,303 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $26,675 Insurance broker organization code? 3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	FLY960176
Policy instance	6
Insurance contract or identification number FLY960176 Number of Individuals Covered 2140 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $50,395 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $964,501 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $50,395 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 78697 )
Policy contract number	10079941001
Policy instance	12
Insurance contract or identification number 10079941001 Number of Individuals Covered 2342 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $4,116 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $119,581 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,116 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000064096482
Policy instance	11
Insurance contract or identification number 000064096482 Number of Individuals Covered 1867 Insurance policy start date 2017-03-12 Insurance policy end date 2018-03-12 Total amount of commissions paid to insurance broker USD $6,328 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $42,188 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,328 Insurance broker organization code? 3 Insurance broker name NFP PROPERTY & CASUALTY SERVICES IN
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK960159
Policy instance	10
Insurance contract or identification number NYK960159 Number of Individuals Covered 1419 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $12,110 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $230,961 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,110 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD074690
Policy instance	8
Insurance contract or identification number NYD074690 Number of Individuals Covered 1442 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,768 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $31,383 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,768 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	Y0K960192
Policy instance	7
Insurance contract or identification number Y0K960192 Number of Individuals Covered 801 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $2,660 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $50,708 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,660 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	009336
Policy instance	1
Insurance contract or identification number 009336 Number of Individuals Covered 10 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $250 Total amount of fees paid to insurance company USD $0 Health 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 $250 Insurance broker organization code? 3 Insurance broker name DANIEL ALBERT
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK600053
Policy instance	9
Insurance contract or identification number NYK600053 Number of Individuals Covered 614 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $6,509 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $124,198 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,509 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008627
Policy instance	2
Insurance contract or identification number 008627 Number of Individuals Covered 2661 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $32,897 Total amount of fees paid to insurance company USD $0 Health 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 $32,897 Insurance broker organization code? 3 Insurance broker name DANIEL ALBERT
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	011610
Policy instance	3
Insurance contract or identification number 011610 Number of Individuals Covered 1075 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $13,300 Total amount of fees paid to insurance company USD $0 Health 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 $13,300 Insurance broker organization code? 3 Insurance broker name DANIEL ALBERT
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	4
Insurance contract or identification number 702404 Number of Individuals Covered 331 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $2,805 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $94,952 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,805 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	001530
Policy instance	5
Insurance contract or identification number 001530 Number of Individuals Covered 3436 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $4,990 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,990 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	011610
Policy instance	4
Insurance contract or identification number 011610 Number of Individuals Covered 972 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $8,098 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $8,098 Insurance broker organization code? 3 Insurance broker name DANIEL ALBERT
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK960159
Policy instance	11
Insurance contract or identification number NYK960159 Number of Individuals Covered 2325 Insurance policy start date 2015-01-01 Insurance policy end date 2016-01-01 Total amount of commissions paid to insurance broker USD $13,150 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $229,125 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,150 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	009336
Policy instance	2
Insurance contract or identification number 009336 Number of Individuals Covered 14 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $3,369 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,369 Insurance broker organization code? 3 Insurance broker name ALBERT D DANIEL
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008629
Policy instance	1
Insurance contract or identification number 008629 Number of Individuals Covered 1 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $3,238 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,238 Insurance broker organization code? 3 Insurance broker name ALBERT D DANIEL
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	5
Insurance contract or identification number 702404 Number of Individuals Covered 348 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $2,886 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $96,783 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,886 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	001530
Policy instance	6
Insurance contract or identification number 001530 Number of Individuals Covered 3550 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $4,853 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,853 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	FLY960176
Policy instance	7
Insurance contract or identification number FLY960176 Number of Individuals Covered 2677 Insurance policy start date 2015-01-01 Insurance policy end date 2016-01-01 Total amount of commissions paid to insurance broker USD $52,057 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $915,066 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $52,057 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	Y0K960192
Policy instance	8
Insurance contract or identification number Y0K960192 Number of Individuals Covered 701 Insurance policy start date 2015-01-01 Insurance policy end date 2016-01-01 Total amount of commissions paid to insurance broker USD $3,021 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $52,799 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,021 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD074690
Policy instance	9
Insurance contract or identification number NYD074690 Number of Individuals Covered 1395 Insurance policy start date 2015-01-01 Insurance policy end date 2016-01-01 Total amount of commissions paid to insurance broker USD $1,766 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $32,211 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,766 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK600053
Policy instance	10
Insurance contract or identification number NYK600053 Number of Individuals Covered 701 Insurance policy start date 2015-01-01 Insurance policy end date 2016-01-01 Total amount of commissions paid to insurance broker USD $5,959 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $104,182 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,959 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUE CROSS BLUE SHIELD OF LOUISIANA (National Association of Insurance Commissioners NAIC id number: 81200 )
Policy contract number	77519FF2
Policy instance	13
Insurance contract or identification number 77519FF2 Number of Individuals Covered 79 Insurance policy start date 2015-01-01 Insurance policy end date 2016-01-01 Total amount of commissions paid to insurance broker USD $9,201 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $358,335 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,201 Insurance broker organization code? 3 Insurance broker name HOME AUTOMATION INC
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000064096482
Policy instance	12
Insurance contract or identification number 000064096482 Number of Individuals Covered 1355 Insurance policy start date 2015-03-12 Insurance policy end date 2016-03-12 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT 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 Insurance broker organization code? 3 Insurance broker name BWD GROUP, LLC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008627
Policy instance	3
Insurance contract or identification number 008627 Number of Individuals Covered 2941 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $19,133 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? 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 $19,133 Insurance broker organization code? 3 Insurance broker name ALBERT D DANIEL
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	5
Insurance contract or identification number 702404 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 $2,779 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 $91,825 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,779 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK960159
Policy instance	11
Insurance contract or identification number NYK960159 Number of Individuals Covered 1279 Insurance policy start date 2014-01-01 Insurance policy end date 2015-01-01 Total amount of commissions paid to insurance broker USD $29,219 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 $489,356 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,219 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK600053
Policy instance	10
Insurance contract or identification number NYK600053 Number of Individuals Covered 585 Insurance policy start date 2014-01-01 Insurance policy end date 2015-01-01 Total amount of commissions paid to insurance broker USD $5,613 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 $94,151 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,613 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD074690
Policy instance	9
Insurance contract or identification number NYD074690 Number of Individuals Covered 1407 Insurance policy start date 2014-01-01 Insurance policy end date 2015-01-01 Total amount of commissions paid to insurance broker USD $1,954 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 $32,533 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,954 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000064096482
Policy instance	12
Insurance contract or identification number 000064096482 Number of Individuals Covered 1355 Insurance policy start date 2014-03-12 Insurance policy end date 2015-03-12 Total amount of commissions paid to insurance broker USD $6,400 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 AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $40,000 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,400 Insurance broker organization code? 3 Insurance broker name BWD GROUP, LLC
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	001530
Policy instance	6
Insurance contract or identification number 001530 Number of Individuals Covered 3512 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $2,780 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 $2,780 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	011610
Policy instance	4
Insurance contract or identification number 011610 Number of Individuals Covered 782 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $4,210 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,210 Insurance broker organization code? 3 Insurance broker name ALBERT D DANIEL
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	009336
Policy instance	2
Insurance contract or identification number 009336 Number of Individuals Covered 21 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $186 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 Were dividends or retroactive rate refunds paid as a credit? 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 $186 Insurance broker organization code? 3 Insurance broker name ALBERT D DANIEL
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008627
Policy instance	3
Insurance contract or identification number 008627 Number of Individuals Covered 3060 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $16,149 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 Were dividends or retroactive rate refunds paid as a credit? 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 $16,149 Insurance broker organization code? 3 Insurance broker name ALBERT D DANIEL
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008629
Policy instance	1
Insurance contract or identification number 008629 Number of Individuals Covered 1 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $12 Total amount of fees paid to insurance company USD $705 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12 Insurance broker organization code? 3 Insurance broker name ALBERT D DANIEL
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	FLY960176
Policy instance	7
Insurance contract or identification number FLY960176 Number of Individuals Covered 2681 Insurance policy start date 2014-01-01 Insurance policy end date 2015-01-01 Total amount of commissions paid to insurance broker USD $70,936 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 $1,181,761 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $70,936 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	Y0K960192
Policy instance	8
Insurance contract or identification number Y0K960192 Number of Individuals Covered 585 Insurance policy start date 2014-01-01 Insurance policy end date 2015-01-01 Total amount of commissions paid to insurance broker USD $2,846 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 AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $47,357 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,846 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000064096482
Policy instance	15
Insurance contract or identification number 000064096482 Number of Individuals Covered 1355 Insurance policy start date 2013-03-12 Insurance policy end date 2014-03-12 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008629
Policy instance	2
Insurance contract or identification number 008629 Number of Individuals Covered 6 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK960159
Policy instance	14
Insurance contract or identification number NYK960159 Number of Individuals Covered 1310 Insurance policy start date 2013-01-01 Insurance policy end date 2014-01-01 Total amount of commissions paid to insurance broker USD $7,316 Total amount of fees paid to insurance company USD $-402 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 $120,233 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,316 Amount paid for insurance broker fees -402 Additional information about fees paid to insurance broker SUPP. COMMISSION & OVERRIDE Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK600053
Policy instance	13
Insurance contract or identification number NYK600053 Number of Individuals Covered 590 Insurance policy start date 2013-01-01 Insurance policy end date 2014-01-01 Total amount of commissions paid to insurance broker USD $7,155 Total amount of fees paid to insurance company USD $-292 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 $119,955 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,155 Amount paid for insurance broker fees -292 Additional information about fees paid to insurance broker SUPP. COMMISSION & OVERRIDE Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD074690
Policy instance	12
Insurance contract or identification number NYD074690 Number of Individuals Covered 473 Insurance policy start date 2013-01-01 Insurance policy end date 2014-01-01 Total amount of commissions paid to insurance broker USD $1,876 Total amount of fees paid to insurance company USD $-83 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 $32,563 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,876 Amount paid for insurance broker fees -83 Additional information about fees paid to insurance broker SUPP. COMMISSION & OVERRIDE Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
SAINT MARYS HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 11079 )
Policy contract number	ARID0003458
Policy instance	1
Insurance contract or identification number ARID0003458 Number of Individuals Covered 161 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $39,465 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 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 $39,465 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	YDK960192
Policy instance	11
Insurance contract or identification number YDK960192 Number of Individuals Covered 913 Insurance policy start date 2013-01-01 Insurance policy end date 2014-01-01 Total amount of commissions paid to insurance broker USD $3,581 Total amount of fees paid to insurance company USD $-143 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 AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $60,165 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,581 Amount paid for insurance broker fees -143 Additional information about fees paid to insurance broker SUPP. COMMISSION & OVERRIDE Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	FLY960176
Policy instance	10
Insurance contract or identification number FLY960176 Number of Individuals Covered 1878 Insurance policy start date 2013-01-01 Insurance policy end date 2014-01-01 Total amount of commissions paid to insurance broker USD $78,064 Total amount of fees paid to insurance company USD $-3,379 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 $1,309,660 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $78,064 Amount paid for insurance broker fees -3379 Additional information about fees paid to insurance broker SUPP. COMMISSION & OVERRIDE Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUE CROSS AND BLUE SHIELD OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )
Policy contract number	MC0048 000
Policy instance	9
Insurance contract or identification number MC0048 000 Number of Individuals Covered 85 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 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $273,353 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	001530
Policy instance	8
Insurance contract or identification number 001530 Number of Individuals Covered 3603 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $5,042 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 $5,042 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	7
Insurance contract or identification number 702404 Number of Individuals Covered 357 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $3,002 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $98,576 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,002 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	011610
Policy instance	6
Insurance contract or identification number 011610 Number of Individuals Covered 597 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008627
Policy instance	5
Insurance contract or identification number 008627 Number of Individuals Covered 3660 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	009336
Policy instance	4
Insurance contract or identification number 009336 Number of Individuals Covered 28 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008628
Policy instance	3
Insurance contract or identification number 008628 Number of Individuals Covered 10 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	YDK960192
Policy instance	11
Insurance contract or identification number YDK960192 Number of Individuals Covered 820 Insurance policy start date 2012-01-01 Insurance policy end date 2013-01-01 Total amount of commissions paid to insurance broker USD $3,315 Total amount of fees paid to insurance company USD $143 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 AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $57,631 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,315 Amount paid for insurance broker fees 143 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD074690
Policy instance	12
Insurance contract or identification number NYD074690 Number of Individuals Covered 477 Insurance policy start date 2012-01-01 Insurance policy end date 2013-01-01 Total amount of commissions paid to insurance broker USD $1,835 Total amount of fees paid to insurance company USD $83 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 $33,357 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,835 Amount paid for insurance broker fees 83 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK600053
Policy instance	13
Insurance contract or identification number NYK600053 Number of Individuals Covered 732 Insurance policy start date 2012-01-01 Insurance policy end date 2013-01-01 Total amount of commissions paid to insurance broker USD $6,756 Total amount of fees paid to insurance company USD $293 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 $117,443 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,756 Amount paid for insurance broker fees 293 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK960159
Policy instance	14
Insurance contract or identification number NYK960159 Number of Individuals Covered 1365 Insurance policy start date 2012-01-01 Insurance policy end date 2013-01-01 Total amount of commissions paid to insurance broker USD $8,449 Total amount of fees paid to insurance company USD $402 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 $147,650 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,449 Amount paid for insurance broker fees 402 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000064096482
Policy instance	15
Insurance contract or identification number 000064096482 Number of Individuals Covered 1355 Insurance policy start date 2012-03-12 Insurance policy end date 2013-03-12 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	FLY960176
Policy instance	10
Insurance contract or identification number FLY960176 Number of Individuals Covered 2094 Insurance policy start date 2012-01-01 Insurance policy end date 2013-01-01 Total amount of commissions paid to insurance broker USD $71,982 Total amount of fees paid to insurance company USD $3,379 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 $1,256,504 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $71,982 Amount paid for insurance broker fees 3379 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	01530
Policy instance	8
Insurance contract or identification number 01530 Number of Individuals Covered 4074 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $5,261 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 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 $5,261 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	7
Insurance contract or identification number 702404 Number of Individuals Covered 423 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $3,507 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 $115,723 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,507 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	011610
Policy instance	6
Insurance contract or identification number 011610 Number of Individuals Covered 371 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008627
Policy instance	5
Insurance contract or identification number 008627 Number of Individuals Covered 4403 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008628
Policy instance	3
Insurance contract or identification number 008628 Number of Individuals Covered 11 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008629
Policy instance	2
Insurance contract or identification number 008629 Number of Individuals Covered 8 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SAINT MARYS HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 11079 )
Policy contract number	ARID0003458
Policy instance	1
Insurance contract or identification number ARID0003458 Number of Individuals Covered 164 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $38,758 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 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 $38,758 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	009336
Policy instance	4
Insurance contract or identification number 009336 Number of Individuals Covered 34 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS AND BLUE SHIELD OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )
Policy contract number	MC0048 000
Policy instance	9
Insurance contract or identification number MC0048 000 Number of Individuals Covered 87 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 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $267,521 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000064096482
Policy instance	15
Insurance contract or identification number 000064096482 Number of Individuals Covered 1355 Insurance policy start date 2011-03-12 Insurance policy end date 2012-03-12 Total amount of commissions paid to insurance broker USD $6,450 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 AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $43,000 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008629
Policy instance	2
Insurance contract or identification number 008629 Number of Individuals Covered 14 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008628
Policy instance	3
Insurance contract or identification number 008628 Number of Individuals Covered 13 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	009336
Policy instance	4
Insurance contract or identification number 009336 Number of Individuals Covered 46 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	011610
Policy instance	6
Insurance contract or identification number 011610 Number of Individuals Covered 216 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008627
Policy instance	5
Insurance contract or identification number 008627 Number of Individuals Covered 4671 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	7
Insurance contract or identification number 702404 Number of Individuals Covered 427 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $4,077 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 $118,658 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	01530
Policy instance	8
Insurance contract or identification number 01530 Number of Individuals Covered 4110 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $5,438 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS AND BLUE SHIELD OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )
Policy contract number	MC0048 1
Policy instance	9
Insurance contract or identification number MC0048 1 Number of Individuals Covered 89 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 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $244,883 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	FLY960176
Policy instance	10
Insurance contract or identification number FLY960176 Number of Individuals Covered 2118 Insurance policy start date 2011-01-01 Insurance policy end date 2012-01-01 Total amount of commissions paid to insurance broker USD $53,322 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 $1,133,588 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	YDK960192
Policy instance	11
Insurance contract or identification number YDK960192 Number of Individuals Covered 816 Insurance policy start date 2011-01-01 Insurance policy end date 2012-01-01 Total amount of commissions paid to insurance broker USD $2,521 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 AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $53,171 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD074690
Policy instance	12
Insurance contract or identification number NYD074690 Number of Individuals Covered 489 Insurance policy start date 2011-01-01 Insurance policy end date 2012-01-01 Total amount of commissions paid to insurance broker USD $2,018 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 $32,041 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK600053
Policy instance	13
Insurance contract or identification number NYK600053 Number of Individuals Covered 747 Insurance policy start date 2011-01-01 Insurance policy end date 2012-01-01 Total amount of commissions paid to insurance broker USD $4,530 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $113,652 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK960159
Policy instance	14
Insurance contract or identification number NYK960159 Number of Individuals Covered 1371 Insurance policy start date 2011-01-01 Insurance policy end date 2012-01-01 Total amount of commissions paid to insurance broker USD $5,827 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 $202,107 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SAINT MARYS HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 11079 )
Policy contract number	ARID0003458
Policy instance	1
Insurance contract or identification number ARID0003458 Number of Individuals Covered 181 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $40,027 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 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008628
Policy instance	3
Insurance contract or identification number 008628 Number of Individuals Covered 31 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK960159
Policy instance	15
Insurance contract or identification number NYK960159 Insurance policy start date 2010-01-01 Insurance policy end date 2011-01-01 Total amount of commissions paid to insurance broker USD $12,784 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 $243,402 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,784 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008629
Policy instance	2
Insurance contract or identification number 008629 Number of Individuals Covered 62 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	009336
Policy instance	4
Insurance contract or identification number 009336 Number of Individuals Covered 93 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	008627
Policy instance	5
Insurance contract or identification number 008627 Number of Individuals Covered 5041 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 Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number	011610
Policy instance	6
Insurance contract or identification number 011610 Number of Individuals Covered 142 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	702404
Policy instance	7
Insurance contract or identification number 702404 Number of Individuals Covered 417 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $2,880 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 $114,229 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,880 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
BLUE CROSS AND BLUE SHIELD OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )
Policy contract number	MC0048 1
Policy instance	9
Insurance contract or identification number MC0048 1 Number of Individuals Covered 89 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 $230,380 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Insurance broker organization code? 3 Insurance broker name
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number	1530
Policy instance	8
Insurance contract or identification number 1530 Number of Individuals Covered 4606 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $6,248 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 $6,248 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000064096482
Policy instance	10
Insurance contract or identification number 000064096482 Number of Individuals Covered 1355 Insurance policy start date 2010-03-12 Insurance policy end date 2011-03-12 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	FLY960176
Policy instance	11
Insurance contract or identification number FLY960176 Insurance policy start date 2010-01-01 Insurance policy end date 2011-01-01 Total amount of commissions paid to insurance broker USD $71,809 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 $1,345,520 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $71,809 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	YDK960192
Policy instance	12
Insurance contract or identification number YDK960192 Insurance policy start date 2010-01-01 Insurance policy end date 2011-01-01 Total amount of commissions paid to insurance broker USD $10,349 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 AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $69,875 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,349 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD074690
Policy instance	13
Insurance contract or identification number NYD074690 Insurance policy start date 2010-01-01 Insurance policy end date 2011-01-01 Total amount of commissions paid to insurance broker USD $1,868 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 $32,775 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,868 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYK600053
Policy instance	14
Insurance contract or identification number NYK600053 Insurance policy start date 2010-01-01 Insurance policy end date 2011-01-01 Total amount of commissions paid to insurance broker USD $7,943 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 $150,832 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,943 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
SAINT MARY'S HEALTHFIRST (National Association of Insurance Commissioners NAIC id number: 95793 )
Policy contract number	H01139
Policy instance	1
Insurance contract or identification number H01139 Number of Individuals Covered 177 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 $50,091 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 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 50091 Additional information about fees paid to insurance broker BROKERAGE FEES PAID Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC