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BLUE CROSS GROUP PLAN 401k Plan overview

Plan NameBLUE CROSS GROUP PLAN
Plan identification number 504

BLUE CROSS GROUP PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Dental
  • Vision
  • Other welfare benefit cover
  • Collectively bargained welfare benefit arrangement under Code section 419A(f)(5).

401k Sponsoring company profile

PALL CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:PALL CORPORATION
Employer identification number (EIN):111541330
NAIC Classification:339900

Additional information about PALL CORPORATION

Jurisdiction of Incorporation: New York Department of State
Incorporation Date: 1946-07-31
Company Identification Number: 59466
Legal Registered Office Address: 28 LIBERTY STREET
New York
NEW YORK
United States of America (USA)
10005

More information about PALL CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLUE CROSS GROUP PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5042015-03-01JEFF MOLIN
5042014-03-01JULIE TAYLOR JULIE TAYLOR2015-08-28
5042013-03-01JULIE TAYLOR JULIE TAYLOR2014-10-10
5042012-03-01JULIE TAYLOR JULIE TAYLOR2013-12-04
5042010-03-01JAMES PORRETTO
5042009-03-01JAMES PORRETTO

Plan Statistics for BLUE CROSS GROUP PLAN

401k plan membership statisitcs for BLUE CROSS GROUP PLAN

Measure Date Value
2015: BLUE CROSS GROUP PLAN 2015 401k membership
Total participants, beginning-of-year2015-03-01339
Total number of active participants reported on line 7a of the Form 55002015-03-01339
Number of retired or separated participants receiving benefits2015-03-010
Number of other retired or separated participants entitled to future benefits2015-03-010
Total of all active and inactive participants2015-03-01339
2014: BLUE CROSS GROUP PLAN 2014 401k membership
Total participants, beginning-of-year2014-03-01351
Total number of active participants reported on line 7a of the Form 55002014-03-01339
Number of retired or separated participants receiving benefits2014-03-010
Number of other retired or separated participants entitled to future benefits2014-03-010
Total of all active and inactive participants2014-03-01339
2013: BLUE CROSS GROUP PLAN 2013 401k membership
Total participants, beginning-of-year2013-03-01374
Total number of active participants reported on line 7a of the Form 55002013-03-01351
Number of retired or separated participants receiving benefits2013-03-010
Number of other retired or separated participants entitled to future benefits2013-03-010
Total of all active and inactive participants2013-03-01351
2012: BLUE CROSS GROUP PLAN 2012 401k membership
Total participants, beginning-of-year2012-03-01360
Total number of active participants reported on line 7a of the Form 55002012-03-01374
Total of all active and inactive participants2012-03-01374
2010: BLUE CROSS GROUP PLAN 2010 401k membership
Total participants, beginning-of-year2010-03-01351
Total number of active participants reported on line 7a of the Form 55002010-03-01385
Number of retired or separated participants receiving benefits2010-03-011
Total of all active and inactive participants2010-03-01386
2009: BLUE CROSS GROUP PLAN 2009 401k membership
Total participants, beginning-of-year2009-03-01347
Total number of active participants reported on line 7a of the Form 55002009-03-01349
Number of retired or separated participants receiving benefits2009-03-012
Number of other retired or separated participants entitled to future benefits2009-03-010
Total of all active and inactive participants2009-03-01351
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2009-03-010
Total participants2009-03-01351
Number of participants with account balances2009-03-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2009-03-010

Form 5500 Responses for BLUE CROSS GROUP PLAN

2015: BLUE CROSS GROUP PLAN 2015 form 5500 responses
2015-03-01Type of plan entitySingle employer plan
2015-03-01Submission has been amendedNo
2015-03-01This submission is the final filingNo
2015-03-01This return/report is a short plan year return/report (less than 12 months)No
2015-03-01Plan is a collectively bargained planYes
2015-03-01Plan funding arrangement – InsuranceYes
2015-03-01Plan benefit arrangement – InsuranceYes
2014: BLUE CROSS GROUP PLAN 2014 form 5500 responses
2014-03-01Type of plan entitySingle employer plan
2014-03-01Submission has been amendedNo
2014-03-01This submission is the final filingNo
2014-03-01This return/report is a short plan year return/report (less than 12 months)No
2014-03-01Plan is a collectively bargained planYes
2014-03-01Plan funding arrangement – InsuranceYes
2014-03-01Plan benefit arrangement – InsuranceYes
2013: BLUE CROSS GROUP PLAN 2013 form 5500 responses
2013-03-01Type of plan entitySingle employer plan
2013-03-01Submission has been amendedNo
2013-03-01This submission is the final filingNo
2013-03-01This return/report is a short plan year return/report (less than 12 months)No
2013-03-01Plan is a collectively bargained planYes
2013-03-01Plan funding arrangement – InsuranceYes
2013-03-01Plan benefit arrangement – InsuranceYes
2012: BLUE CROSS GROUP PLAN 2012 form 5500 responses
2012-03-01Type of plan entitySingle employer plan
2012-03-01Submission has been amendedNo
2012-03-01This submission is the final filingNo
2012-03-01This return/report is a short plan year return/report (less than 12 months)No
2012-03-01Plan is a collectively bargained planYes
2012-03-01Plan funding arrangement – InsuranceYes
2012-03-01Plan benefit arrangement – InsuranceYes
2010: BLUE CROSS GROUP PLAN 2010 form 5500 responses
2010-03-01Type of plan entitySingle employer plan
2010-03-01Submission has been amendedYes
2010-03-01This submission is the final filingNo
2010-03-01This return/report is a short plan year return/report (less than 12 months)No
2010-03-01Plan is a collectively bargained planYes
2010-03-01Plan funding arrangement – InsuranceYes
2010-03-01Plan benefit arrangement – InsuranceYes
2009: BLUE CROSS GROUP PLAN 2009 form 5500 responses
2009-03-01Type of plan entitySingle employer plan
2009-03-01Submission has been amendedNo
2009-03-01This submission is the final filingNo
2009-03-01This return/report is a short plan year return/report (less than 12 months)No
2009-03-01Plan is a collectively bargained planYes
2009-03-01Plan funding arrangement – InsuranceYes
2009-03-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

FAMILY & CHILDREN'S SERVICE OF ITHACA (National Association of Insurance Commissioners NAIC id number: 62142 )
Policy contract number100641
Policy instance 1
Insurance contract or identification number100641
Number of Individuals Covered339
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberPTM-001
Policy instance 1
Insurance contract or identification numberPTM-001
Number of Individuals Covered855
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $37,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number510182
Policy instance 4
Insurance contract or identification number510182
Number of Individuals Covered0
Insurance policy start date2014-03-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $5,937
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,937
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAON CONSULTING
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number00045263
Policy instance 3
Insurance contract or identification number00045263
Number of Individuals Covered784
Insurance policy start date2014-03-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $91,280
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $91,280
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAON CONSULTING
FAMILY & CHILDREN'S SERVICE OF ITHACA (National Association of Insurance Commissioners NAIC id number: 62142 )
Policy contract number100641
Policy instance 2
Insurance contract or identification number100641
Number of Individuals Covered339
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number510182
Policy instance 1
Insurance contract or identification number510182
Number of Individuals Covered791
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $9,070
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,427
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAON CONSULTING
DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberPTM-001
Policy instance 2
Insurance contract or identification numberPTM-001
Number of Individuals Covered882
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $46,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number00045263
Policy instance 3
Insurance contract or identification number00045263
Number of Individuals Covered816
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $113,910
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $92,548
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAON CONSULTING
FAMILY & CHILDREN'S SERVICE OF ITHACA (National Association of Insurance Commissioners NAIC id number: 62142 )
Policy contract number100641
Policy instance 4
Insurance contract or identification number100641
Number of Individuals Covered351
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEAP
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberPTM-001
Policy instance 1
Insurance contract or identification numberPTM-001
Number of Individuals Covered984
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $40,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
FAMILY & CHILDREN'S SERVICE OF ITHACA (National Association of Insurance Commissioners NAIC id number: 62142 )
Policy contract number100641
Policy instance 3
Insurance contract or identification number100641
Number of Individuals Covered351
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number00045263
Policy instance 2
Insurance contract or identification number00045263
Number of Individuals Covered900
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $119,741
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $119,741
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH & BENEFITS
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number510182
Policy instance 1
Insurance contract or identification number510182
Number of Individuals Covered953
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $135,864
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
FAMILY & CHILDREN'S SERVICE OF ITHACA (National Association of Insurance Commissioners NAIC id number: 62142 )
Policy contract numberPALL
Policy instance 2
Insurance contract or identification numberPALL
Number of Individuals Covered996
Insurance policy start date2009-08-01
Insurance policy end date2010-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberPTM-001
Policy instance 3
Insurance contract or identification numberPTM-001
Number of Individuals Covered996
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $43,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes

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