401k Plan data: AKF EMPLOYEE BENEFITS PLAN plan

AKF EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	AKF EMPLOYEE BENEFITS PLAN
Plan identification number	501

AKF EMPLOYEE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

AKF GROUP LLC has sponsored the creation of one or more 401k plans.

Company Name: AKF GROUP LLC

Employer identification number (EIN): 133496488

NAIC Classification: 541330
NAIC Description: Engineering Services

Additional information about AKF GROUP LLC

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 2006-12-22

Company Identification Number: 3453101

Legal Registered Office Address: 80 STATE STREET
New York
ALBANY
United States of America (USA)
12207

More information about AKF GROUP LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AKF EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2014-01-01 LOREN ARCARIA LOREN ARCARIA 2015-07-29
501 2013-01-01 PAUL BELLO PAUL BELLO 2014-05-12
501 2012-01-01 MALCOLM HOWARD MALCOLM HOWARD 2013-07-10
501 2011-01-01 MALCOLM HOWARD MALCOLM HOWARD 2012-07-31
501 2009-01-01 PAUL BELLO PAUL BELLO 2010-06-07

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2014-01-01	LOREN ARCARIA	LOREN ARCARIA	2015-07-29
501	2013-01-01	PAUL BELLO	PAUL BELLO	2014-05-12
501	2012-01-01	MALCOLM HOWARD	MALCOLM HOWARD	2013-07-10
501	2011-01-01	MALCOLM HOWARD	MALCOLM HOWARD	2012-07-31
501	2009-01-01	PAUL BELLO	PAUL BELLO	2010-06-07

Plan Statistics for AKF EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for AKF EMPLOYEE BENEFITS PLAN

Measure Date Value
2014: AKF EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 250
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 250
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 250
2013: AKF EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 525
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 250
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 250
2012: AKF EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 269
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 525
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 525
2011: AKF EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 277
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 258
Number of retired or separated participants receiving benefits 2011-01-01 1
Number of other retired or separated participants entitled to future benefits 2011-01-01 10
Total of all active and inactive participants 2011-01-01 269
2009: AKF EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 307
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 270
Number of retired or separated participants receiving benefits 2009-01-01 23
Number of other retired or separated participants entitled to future benefits 2009-01-01 4
Total of all active and inactive participants 2009-01-01 297
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 297
Number of participants with account balances 2009-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2014: AKF EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	250
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	250
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	250
2013: AKF EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	525
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	250
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	250
2012: AKF EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	269
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	525
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	525
2011: AKF EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	277
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	258
Number of retired or separated participants receiving benefits	2011-01-01	1
Number of other retired or separated participants entitled to future benefits	2011-01-01	10
Total of all active and inactive participants	2011-01-01	269
2009: AKF EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	307
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	270
Number of retired or separated participants receiving benefits	2009-01-01	23
Number of other retired or separated participants entitled to future benefits	2009-01-01	4
Total of all active and inactive participants	2009-01-01	297
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	297
Number of participants with account balances	2009-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Form 5500 Responses for AKF EMPLOYEE BENEFITS PLAN

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

Insurance Providers Used on plan

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

Policy contract number

000MH622

Policy instance

Insurance contract or identification number	000MH622
Number of Individuals Covered	294
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $9,019
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $305,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,532
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

GMSA0APVT

Policy instance

Insurance contract or identification number	GMSA0APVT
Number of Individuals Covered	25
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-01
Total amount of commissions paid to insurance broker	USD $680
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $2,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $680
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP

EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

SL10000124-131

Policy instance

Insurance contract or identification number	SL10000124-131
Number of Individuals Covered	141
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $310,407
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
Insurance broker organization code?	3
Insurance broker name	J.N. SAVASTA CORP.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

MP0APVT

Policy instance

Insurance contract or identification number	MP0APVT
Number of Individuals Covered	327
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-01
Total amount of commissions paid to insurance broker	USD $358
Total amount of fees paid to insurance company	USD $34
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $3,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $358
Amount paid for insurance broker fees	34
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

GMTD0APVT

Policy instance

Insurance contract or identification number	GMTD0APVT
Number of Individuals Covered	327
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-01
Total amount of commissions paid to insurance broker	USD $4,617
Total amount of fees paid to insurance company	USD $923
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,617
Amount paid for insurance broker fees	923
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

720938

Policy instance

Insurance contract or identification number	720938
Number of Individuals Covered	250
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $81,301
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,520
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

GMLP0APVT

Policy instance

Insurance contract or identification number	GMLP0APVT
Number of Individuals Covered	327
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-01
Total amount of commissions paid to insurance broker	USD $3,268
Total amount of fees paid to insurance company	USD $491
Other welfare benefits provided	SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $37,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,268
Amount paid for insurance broker fees	491
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

7507P83

Policy instance

Insurance contract or identification number	7507P83
Number of Individuals Covered	163
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-01
Total amount of commissions paid to insurance broker	USD $1,087
Total amount of fees paid to insurance company	USD $381
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,087
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker name	THE MAXON COMPANY

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

GLCL0APVT

Policy instance

Insurance contract or identification number	GLCL0APVT
Number of Individuals Covered	327
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-01
Total amount of commissions paid to insurance broker	USD $2,861
Total amount of fees paid to insurance company	USD $435
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,861
Amount paid for insurance broker fees	435
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

GCEL0APVT

Policy instance

Insurance contract or identification number	GCEL0APVT
Number of Individuals Covered	45
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,238
Total amount of fees paid to insurance company	USD $349
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $28,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,238
Amount paid for insurance broker fees	349
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

904228

Policy instance

Insurance contract or identification number	904228
Number of Individuals Covered	181
Insurance policy start date	2013-01-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $431
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $431
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORPORATION

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

904544

Policy instance

Insurance contract or identification number	904544
Number of Individuals Covered	48
Insurance policy start date	2013-01-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,018
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	FLEX ADD
Welfare Benefit Premiums Paid to Carrier	USD $17,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,018
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORPORATION

EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )

Policy contract number

G1921

Policy instance

Insurance contract or identification number	G1921
Number of Individuals Covered	601
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $70,259
Total amount of fees paid to insurance company	USD $18,880
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,999,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,560
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	INCENTIVES,EDUCATION,COMMUNICATION AND TRADING
Insurance broker name	J N SAVASTA CORP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000APVT

Policy instance

Insurance contract or identification number	G000APVT
Number of Individuals Covered	311
Insurance policy start date	2013-06-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,259
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,259
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP.

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

G000APVT

Policy instance

Insurance contract or identification number	G000APVT
Number of Individuals Covered	311
Insurance policy start date	2013-06-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,953
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	ADD
Welfare Benefit Premiums Paid to Carrier	USD $60,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,953
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

G000APVT

Policy instance

Insurance contract or identification number	G000APVT
Number of Individuals Covered	76
Insurance policy start date	2013-07-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,206
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $16,824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,206
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP.

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

580878

Policy instance

Insurance contract or identification number	580878
Number of Individuals Covered	290
Insurance policy start date	2013-01-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $2,792
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	ADD
Welfare Benefit Premiums Paid to Carrier	USD $55,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,792
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORPORATION

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3329703

Policy instance

Insurance contract or identification number	3329703
Number of Individuals Covered	286
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $11,392
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $308,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,392
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORP.

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

299459

Policy instance

Insurance contract or identification number	299459
Number of Individuals Covered	257
Insurance policy start date	2013-01-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	FLEX STD
Welfare Benefit Premiums Paid to Carrier	USD $15,286
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
Insurance broker organization code?	3
Insurance broker name	NO BROKERS FOR THIS POLICY

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

75 07P83

Policy instance

Insurance contract or identification number	75 07P83
Number of Individuals Covered	174
Insurance policy start date	2013-06-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $795
Total amount of fees paid to insurance company	USD $265
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $795
Amount paid for insurance broker fees	265
Additional information about fees paid to insurance broker	ADMINISTRATION ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	J N SAVASTA CORPORATION

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

299491

Policy instance

Insurance contract or identification number	299491
Number of Individuals Covered	27
Insurance policy start date	2013-01-01
Insurance policy end date	2013-05-31
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 $6,080
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
Insurance broker organization code?	3
Insurance broker name	NO BROKERS FOR THIS POLICY

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

580878

Policy instance

Insurance contract or identification number	580878
Number of Individuals Covered	293
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,784
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	ADD
Welfare Benefit Premiums Paid to Carrier	USD $127,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,043
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS INC.

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

299491

Policy instance

Insurance contract or identification number	299491
Number of Individuals Covered	27
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,277
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,291
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $844
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS INC.

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

904228

Policy instance

Insurance contract or identification number	904228
Number of Individuals Covered	183
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $711
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $453
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS INC.

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

Policy contract number

861252G

Policy instance

Insurance contract or identification number	861252G
Number of Individuals Covered	100
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,971
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
Insurance broker organization code?	1
Insurance broker name	HOME OFFICE DIRECT

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

904544

Policy instance

Insurance contract or identification number	904544
Number of Individuals Covered	46
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,904
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $34,561
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,415
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS INC.

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

299459

Policy instance

Insurance contract or identification number	299459
Number of Individuals Covered	254
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,602
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	FLEX STD
Welfare Benefit Premiums Paid to Carrier	USD $39,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,641
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS INC.

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

45758000

Policy instance

Insurance contract or identification number	45758000
Number of Individuals Covered	5
Insurance policy start date	2012-01-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $3,008
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $170,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	SINGER NELSON CHARLMERS INC.

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

Policy contract number

3329703

Policy instance

Insurance contract or identification number	3329703
Number of Individuals Covered	278
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $11,264
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $303,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,848
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JN SAVASTA CORP.

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

Policy contract number

AG18117

Policy instance

Insurance contract or identification number	AG18117
Number of Individuals Covered	525
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $107,633
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,616,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,599
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J.N.SAVASTA CORP.

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

299459

Policy instance

Insurance contract or identification number	299459
Number of Individuals Covered	276
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,016
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

580878

Policy instance

Insurance contract or identification number	580878
Number of Individuals Covered	318
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,810
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	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $140,119
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

904228

Policy instance

Insurance contract or identification number	904228
Number of Individuals Covered	194
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,284
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,561
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

3329703

Policy instance

Insurance contract or identification number	3329703
Number of Individuals Covered	295
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $10,718
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $290,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

AG18117

Policy instance

Insurance contract or identification number	AG18117
Number of Individuals Covered	624
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $123,181
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,468,120
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

299491

Policy instance

Insurance contract or identification number	299491
Number of Individuals Covered	26
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $978
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

904544

Policy instance

Insurance contract or identification number	904544
Number of Individuals Covered	49
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,372
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $29,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

904493

Policy instance

Insurance contract or identification number	904493
Number of Individuals Covered	96
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $208
Total amount of fees paid to insurance company	USD $26
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $208
Amount paid for insurance broker fees	26
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS INC

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

904228

Policy instance

Insurance contract or identification number	904228
Number of Individuals Covered	231
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $1,251
Total amount of fees paid to insurance company	USD $104
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,251
Amount paid for insurance broker fees	104
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS INC

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

904544

Policy instance

Insurance contract or identification number	904544
Number of Individuals Covered	43
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $3,505
Total amount of fees paid to insurance company	USD $292
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $23,370
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,505
Amount paid for insurance broker fees	292
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS INC

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

Policy contract number

30004538

Policy instance

Insurance contract or identification number	30004538
Number of Individuals Covered	319
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,876
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $50,133
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	0
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS

CIGNA DENTAL HEALTH OF TEXAS, INC. (National Association of Insurance Commissioners NAIC id number: 95037 )

Policy contract number

3329703

Policy instance

Insurance contract or identification number	3329703
Number of Individuals Covered	1
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $2
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $62
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
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS

CIGNA DENTAL HEALTH OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47041 )

Policy contract number

3329703

Policy instance

Insurance contract or identification number	3329703
Number of Individuals Covered	2
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $38
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $870
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
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS

CIGNA DENTAL HEALTH OF NEW JERSEY, INC. (National Association of Insurance Commissioners NAIC id number: 11167 )

Policy contract number

3329703

Policy instance

Insurance contract or identification number	3329703
Number of Individuals Covered	5
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $94
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $94
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS

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

Policy contract number

3329703

Policy instance

Insurance contract or identification number	3329703
Number of Individuals Covered	635
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $142,369
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	PREPAID DENTAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $454,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $142,369
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

580878

Policy instance

Insurance contract or identification number	580878
Number of Individuals Covered	309
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $7,222
Total amount of fees paid to insurance company	USD $1,582
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $126,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,222
Amount paid for insurance broker fees	1582
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	SINGER NELSON CHARLMERS INC

Potentially related plans

AKF EMPLOYEE BENEFITS PLAN [EIN = 208152697]

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Company Name:	AKF GROUP LLC
Employer identification number (EIN):	133496488
NAIC Classification:	541330
NAIC Description:	Engineering Services

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	2006-12-22
Company Identification Number:	3453101
Legal Registered Office Address:	80 STATE STREET New York ALBANY United States of America (USA) 12207