401k Plan data: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN plan

MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 401k Plan overview

Plan Name	MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN
Plan identification number	501

MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN Benefits

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

401k Sponsoring company profile

MARJAM SUPPLY CO. INC. has sponsored the creation of one or more 401k plans.

Company Name: MARJAM SUPPLY CO. INC.

Employer identification number (EIN): 112507216

NAIC Classification: 423300

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01
501 2021-07-01
501 2020-07-01
501 2019-07-01
501 2018-07-01
501 2017-07-01
501 2016-07-01
501 2015-07-01 BRUCE RESPLER
501 2014-07-01 BRUCE RESPLER
501 2013-07-01 BRUCE RESPLER
501 2012-07-01 MITCHELL KAHN
501 2011-07-01 MITCHELL G KAHN
501 2010-07-01 MITCHELL G KAHN
501 2009-07-01 MITCHELL G KAHN

Plan Statistics for MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN

401k plan membership statisitcs for MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN

Measure Date Value
2022: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 307
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 0
Number of retired or separated participants receiving benefits 2022-07-01 0
Number of other retired or separated participants entitled to future benefits 2022-07-01 0
Total of all active and inactive participants 2022-07-01 0
2021: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 341
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 307
Number of retired or separated participants receiving benefits 2021-07-01 0
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 307
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-07-01 0
Total participants 2021-07-01 307
2020: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 376
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 341
Number of retired or separated participants receiving benefits 2020-07-01 0
Number of other retired or separated participants entitled to future benefits 2020-07-01 0
Total of all active and inactive participants 2020-07-01 341
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-07-01 0
Total participants 2020-07-01 341
2019: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 399
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 376
Number of retired or separated participants receiving benefits 2019-07-01 0
Number of other retired or separated participants entitled to future benefits 2019-07-01 0
Total of all active and inactive participants 2019-07-01 376
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-07-01 0
Total participants 2019-07-01 376
2018: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 416
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 399
Number of retired or separated participants receiving benefits 2018-07-01 0
Number of other retired or separated participants entitled to future benefits 2018-07-01 0
Total of all active and inactive participants 2018-07-01 399
Total participants 2018-07-01 399
2017: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 398
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 416
Total of all active and inactive participants 2017-07-01 416
Total participants 2017-07-01 416
2016: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 393
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 398
Total of all active and inactive participants 2016-07-01 398
Total participants 2016-07-01 398
2015: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 413
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 393
Total of all active and inactive participants 2015-07-01 393
Total participants 2015-07-01 393
2014: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 275
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 413
Total of all active and inactive participants 2014-07-01 413
Total participants 2014-07-01 413
2013: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 159
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 275
Total of all active and inactive participants 2013-07-01 275
Total participants 2013-07-01 275
2012: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 273
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 159
Total of all active and inactive participants 2012-07-01 159
Total participants 2012-07-01 0
2011: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 338
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 273
Total of all active and inactive participants 2011-07-01 273
Total participants 2011-07-01 273
2010: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-07-01 392
Total number of active participants reported on line 7a of the Form 5500 2010-07-01 338
Total of all active and inactive participants 2010-07-01 338
Total participants 2010-07-01 338
2009: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-07-01 366
Total number of active participants reported on line 7a of the Form 5500 2009-07-01 389
Number of retired or separated participants receiving benefits 2009-07-01 3
Total of all active and inactive participants 2009-07-01 392
Total participants 2009-07-01 392

Measure	Date	Value
2022: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	307
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	0
Number of retired or separated participants receiving benefits	2022-07-01	0
Number of other retired or separated participants entitled to future benefits	2022-07-01	0
Total of all active and inactive participants	2022-07-01	0
2021: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	341
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	307
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	307
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-07-01	0
Total participants	2021-07-01	307
2020: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	376
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	341
Number of retired or separated participants receiving benefits	2020-07-01	0
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	341
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-07-01	0
Total participants	2020-07-01	341
2019: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	399
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	376
Number of retired or separated participants receiving benefits	2019-07-01	0
Number of other retired or separated participants entitled to future benefits	2019-07-01	0
Total of all active and inactive participants	2019-07-01	376
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-07-01	0
Total participants	2019-07-01	376
2018: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	416
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	399
Number of retired or separated participants receiving benefits	2018-07-01	0
Number of other retired or separated participants entitled to future benefits	2018-07-01	0
Total of all active and inactive participants	2018-07-01	399
Total participants	2018-07-01	399
2017: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	398
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	416
Total of all active and inactive participants	2017-07-01	416
Total participants	2017-07-01	416
2016: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	393
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	398
Total of all active and inactive participants	2016-07-01	398
Total participants	2016-07-01	398
2015: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	413
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	393
Total of all active and inactive participants	2015-07-01	393
Total participants	2015-07-01	393
2014: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	275
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	413
Total of all active and inactive participants	2014-07-01	413
Total participants	2014-07-01	413
2013: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	159
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	275
Total of all active and inactive participants	2013-07-01	275
Total participants	2013-07-01	275
2012: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	273
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	159
Total of all active and inactive participants	2012-07-01	159
Total participants	2012-07-01	0
2011: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	338
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	273
Total of all active and inactive participants	2011-07-01	273
Total participants	2011-07-01	273
2010: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-07-01	392
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	338
Total of all active and inactive participants	2010-07-01	338
Total participants	2010-07-01	338
2009: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-07-01	366
Total number of active participants reported on line 7a of the Form 5500	2009-07-01	389
Number of retired or separated participants receiving benefits	2009-07-01	3
Total of all active and inactive participants	2009-07-01	392
Total participants	2009-07-01	392

Financial Data on MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN

Measure	Date	Value
2014 : MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2014 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-06-30	No
Was this plan covered by a fidelity bond	2014-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2014-06-30	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-06-30	No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-06-30	No
Were any leases to which the plan was party in default or uncollectible	2014-06-30	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-06-30	No
Was there a failure to transmit to the plan any participant contributions	2014-06-30	No
Has the plan failed to provide any benefit when due under the plan	2014-06-30	No
Did the plan have assets held for investment	2014-06-30	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-06-30	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-06-30	No
Opinion of an independent qualified public accountant for this plan	2014-06-30	Qualified
Accountancy firm name	2014-06-30	MARCUM LLP
Accountancy firm EIN	2014-06-30	111986323

Form 5500 Responses for MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN

2022: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	This submission is the final filing	Yes
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2016: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2015: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2014: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2012: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2011: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2010: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2010 form 5500 responses
2010-07-01	Type of plan entity	Single employer plan
2010-07-01	Plan funding arrangement – Insurance	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes
2009: MARJAM SUPPLY CO. INC. HOSPITALIZATON AND MAJOR MEDICAL INSURANCE PLAN 2009 form 5500 responses
2009-07-01	Type of plan entity	Single employer plan
2009-07-01	Plan funding arrangement – Insurance	Yes
2009-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

Policy instance

Number of Individuals Covered	149
Insurance policy start date	2022-03-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $447,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

52-0807803

Policy instance

Insurance contract or identification number	52-0807803
Number of Individuals Covered	82
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $10,061
Total amount of fees paid to insurance company	USD $248
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER CARE, HOSPITALIZATION CVG
Welfare Benefit Premiums Paid to Carrier	USD $83,085
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,061
Amount paid for insurance broker fees	248
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

82-2723296

Policy instance

Insurance contract or identification number	82-2723296
Number of Individuals Covered	173
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $23,260
Total amount of fees paid to insurance company	USD $579
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER CARE, HOSPITALIZATION CVG
Welfare Benefit Premiums Paid to Carrier	USD $152,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,260
Amount paid for insurance broker fees	579
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 )

Policy contract number

Policy instance

Insurance contract or identification number	14
Number of Individuals Covered	9
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $1,716
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $128,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,716
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

82-2723296

Policy instance

Insurance contract or identification number	82-2723296
Number of Individuals Covered	177
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $22,143
Total amount of fees paid to insurance company	USD $136
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER CARE, HOSPITALIZATION CVG
Welfare Benefit Premiums Paid to Carrier	USD $209,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,143
Amount paid for insurance broker fees	136
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

52-0807803

Policy instance

Insurance contract or identification number	52-0807803
Number of Individuals Covered	92
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $10,535
Total amount of fees paid to insurance company	USD $177
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER CARE, HOSPITALIZATION CVG
Welfare Benefit Premiums Paid to Carrier	USD $100,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,535
Amount paid for insurance broker fees	177
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

Policy instance

Number of Individuals Covered	172
Insurance policy start date	2021-03-01
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
Other welfare benefits provided	ORGAN TRANSPLANT COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $414,236
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	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	2

BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 )

Policy contract number

Policy instance

Insurance contract or identification number	14
Number of Individuals Covered	14
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $2,964
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $139,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,964
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

82-2723296

Policy instance

Insurance contract or identification number	82-2723296
Number of Individuals Covered	209
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $54,365
Total amount of fees paid to insurance company	USD $12,741
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER CARE, HOSPITALIZATION CVG
Welfare Benefit Premiums Paid to Carrier	USD $271,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,365
Amount paid for insurance broker fees	12741
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

52-0807803

Policy instance

Insurance contract or identification number	52-0807803
Number of Individuals Covered	101
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $17,795
Total amount of fees paid to insurance company	USD $46
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER CARE, HOSPITALIZATION CVG
Welfare Benefit Premiums Paid to Carrier	USD $95,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,795
Amount paid for insurance broker fees	46
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

Policy instance

Number of Individuals Covered	169
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $754
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $25,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $754
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 )

Policy contract number

Policy instance

Insurance contract or identification number	14
Number of Individuals Covered	12
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $3,432
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $143,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,432
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

82-2723296

Policy instance

Insurance contract or identification number	82-2723296
Number of Individuals Covered	311
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $36,158
Total amount of fees paid to insurance company	USD $2,353
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER CARE, HOSPITALIZATION CVG
Welfare Benefit Premiums Paid to Carrier	USD $198,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,158
Amount paid for insurance broker fees	2353
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

52-0807803

Policy instance

Insurance contract or identification number	52-0807803
Number of Individuals Covered	131
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $11,011
Total amount of fees paid to insurance company	USD $674
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER CARE, HOSPITALIZATION CVG
Welfare Benefit Premiums Paid to Carrier	USD $95,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,011
Amount paid for insurance broker fees	674
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 )

Policy contract number

Policy instance

Insurance contract or identification number	14
Number of Individuals Covered	11
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $3,276
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $128,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,276
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

Policy instance

Number of Individuals Covered	217
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-28
Total amount of commissions paid to insurance broker	USD $918
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $30,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $918
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 )

Policy contract number

Policy instance

Insurance contract or identification number	14
Number of Individuals Covered	10
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $3,549
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $113,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,549
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

Policy instance

Number of Individuals Covered	237
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $1,004
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ORGAN TRANSPLANT COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $33,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,004
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 )

Policy contract number

Policy instance

Number of Individuals Covered	14
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $4,468
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $132,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 )

Policy contract number

Policy instance

Number of Individuals Covered	18
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $6,438
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $131,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,438
Insurance broker organization code?	3
Insurance broker name	PREFERRED NY FINANCIAL GROUP LLC

BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 )

Policy contract number

Policy instance

Number of Individuals Covered	17
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $4,420
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $117,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,420
Insurance broker organization code?	3
Insurance broker name	PREFERRED NY FINANCIAL GROUP LLC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

853819G

Policy instance

Insurance contract or identification number	853819G
Number of Individuals Covered	83
Insurance policy start date	2014-07-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $284
Total amount of fees paid to insurance company	USD $84
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD-SUPP
Welfare Benefit Premiums Paid to Carrier	USD $1,115
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	84
Insurance broker organization code?	3
Insurance broker name	PROFESSIONAL GROUP PLANS INC

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

N9385

Policy instance

Insurance contract or identification number	N9385
Number of Individuals Covered	107
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $14,166
Total amount of fees paid to insurance company	USD $264
Unemployment Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPPLEMENTAL HEALTH INSURANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $91,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $2
Amount paid for insurance broker fees	12
Additional information about fees paid to insurance broker	FEES, AWARDS, PRIZES, BONUSES, NON-MONETARY COMPENSATION
Insurance broker name	ANN FISCHER

BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 )

Policy contract number

123057

Policy instance

Insurance contract or identification number	123057
Number of Individuals Covered	36
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $8,611
Welfare Benefit Premiums Paid to Carrier	USD $155,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,611
Insurance broker name	WILLIAMS AGENCY INC

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

AJ207

Policy instance

Insurance contract or identification number	AJ207
Number of Individuals Covered	177
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $32,745
Total amount of fees paid to insurance company	USD $25
Other welfare benefits provided	SUPPLEMENTAL HEALTH INSURANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $107,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1
Amount paid for insurance broker fees	1
Additional information about fees paid to insurance broker	FEES, AWARDS, PRIZES, BONUSES, NON-MONETARY COMPENSATION
Insurance broker name	DOMENICO V MAUTARELLI

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00965361

Policy instance

Insurance contract or identification number	00965361
Number of Individuals Covered	3
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $691
Other welfare benefits provided	POS, RX
Welfare Benefit Premiums Paid to Carrier	USD $17,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $691
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT PLANNING LLC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

477231

Policy instance

Insurance contract or identification number	477231
Number of Individuals Covered	186
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $62,764
Total amount of fees paid to insurance company	USD $19,460
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $926,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,494
Insurance broker organization code?	3
Amount paid for insurance broker fees	19460
Additional information about fees paid to insurance broker	2011 SUPPLEMENTAL MEDICAL NEW BUSINESS COMPENSATION
Insurance broker name	PILOT BENEFITS GROUP LLC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

853819G

Policy instance

Insurance contract or identification number	853819G
Number of Individuals Covered	89
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,042
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $521
Insurance broker organization code?	3
Insurance broker name	ADMIN TASKS & THINGS CORP

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

30000109

Policy instance

Insurance contract or identification number	30000109
Number of Individuals Covered	145
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,117
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,381
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,117
Insurance broker organization code?	3
Insurance broker name	PILOT BENEFITS GROUP LLC

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

AJ207

Policy instance

Insurance contract or identification number	AJ207
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $22,456
Total amount of fees paid to insurance company	USD $66
Other welfare benefits provided	SUPPLEMENTAL HEALTH INSURANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $79,846
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
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES, AWARDS, PRIZES, BONUSES, NON-MONETARY COMPENSATION
Amount paid for insurance broker fees	8
Insurance broker name	DOMENICO MAUTARELLI

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00965361

Policy instance

Insurance contract or identification number	00965361
Number of Individuals Covered	5
Insurance policy start date	2011-05-01
Insurance policy end date	2012-04-30
Total amount of commissions paid to insurance broker	USD $585
Other welfare benefits provided	POS, RX
Welfare Benefit Premiums Paid to Carrier	USD $14,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 )

Policy contract number

123057

Policy instance

Insurance contract or identification number	123057
Number of Individuals Covered	34
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $8,888
Welfare Benefit Premiums Paid to Carrier	USD $158,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

OGL-853819

Policy instance

Insurance contract or identification number	OGL-853819
Number of Individuals Covered	154
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $1,314
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

30000109

Policy instance

Insurance contract or identification number	30000109
Number of Individuals Covered	167
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $1,265
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

N9385

Policy instance

Insurance contract or identification number	N9385
Number of Individuals Covered	100
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $14,932
Total amount of fees paid to insurance company	USD $26
Unemployment Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPPLEMENTAL HEALTH INSURANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $92,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

AJ207

Policy instance

Insurance contract or identification number	AJ207
Number of Individuals Covered	92
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $13,670
Total amount of fees paid to insurance company	USD $2
Other welfare benefits provided	SUPPLEMENTAL HEALTH INSURANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $60,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

OGL-853819

Policy instance

Insurance contract or identification number	OGL-853819
Number of Individuals Covered	99
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,180
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

AJ207

Policy instance

Insurance contract or identification number	AJ207
Number of Individuals Covered	68
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $16,734
Total amount of fees paid to insurance company	USD $1,013
Other welfare benefits provided	SUPPLEMENTAL HEALTH INSURANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $51,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

N9385

Policy instance

Insurance contract or identification number	N9385
Number of Individuals Covered	106
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $14,131
Total amount of fees paid to insurance company	USD $130
Unemployment Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPPLEMENTAL HEALTH INSURANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $95,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GLT-853819

Policy instance

Insurance contract or identification number	GLT-853819
Number of Individuals Covered	154
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

000010129525

Policy instance

Insurance contract or identification number	000010129525
Number of Individuals Covered	96
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,308
Total amount of fees paid to insurance company	USD $60
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $12,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

000010129524

Policy instance

Insurance contract or identification number	000010129524
Number of Individuals Covered	91
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $2,598
Total amount of fees paid to insurance company	USD $96
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

JB490

Policy instance

Insurance contract or identification number	JB490
Number of Individuals Covered	262
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $5,408
Total amount of fees paid to insurance company	USD $1,282
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, OPTIONAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $43,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

3333040

Policy instance

Insurance contract or identification number	3333040
Number of Individuals Covered	542
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $105,283
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $311,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

30000109

Policy instance

Insurance contract or identification number	30000109
Number of Individuals Covered	168
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,229
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,108
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

TM05595669

Policy instance

Insurance contract or identification number	TM05595669
Number of Individuals Covered	427
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $4,234
Total amount of fees paid to insurance company	USD $1,476
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $155,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GRH-853819

Policy instance

Insurance contract or identification number	GRH-853819
Number of Individuals Covered	154
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00965361

Policy instance

Insurance contract or identification number	00965361
Number of Individuals Covered	1
Insurance policy start date	2009-05-01
Insurance policy end date	2010-04-30
Total amount of commissions paid to insurance broker	USD $614
Other welfare benefits provided	POS, RX
Welfare Benefit Premiums Paid to Carrier	USD $15,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	MARJAM SUPPLY CO. INC.
Employer identification number (EIN):	112507216
NAIC Classification:	423300