401k Plan data: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN plan

CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN
Plan identification number	501

CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

CRYSTAL RUN HEALTHCARE PHYSICIANS, LLP has sponsored the creation of one or more 401k plans.

Company Name: CRYSTAL RUN HEALTHCARE PHYSICIANS, LLP

Employer identification number (EIN): 133843560

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Additional information about CRYSTAL RUN HEALTHCARE PHYSICIANS, LLP

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1995-07-26

Company Identification Number: 1942375

Legal Registered Office Address: 155 CRYSTAL RUN RD

MIDDLETOWN
United States of America (USA)
10941

More information about CRYSTAL RUN HEALTHCARE PHYSICIANS, LLP

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 STEVEN ZENG 2023-10-16
501 2021-01-01 MARY DEFREITAS 2022-09-19
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 MARY DEFREITAS HAL TEITELBAUM 2018-10-15
501 2016-01-01 MARY DEFREITAS HAL TEITELBAUM 2017-10-27
501 2015-01-01 MARY DEFREITAS HAL TEITELBAUM 2016-10-14
501 2014-01-01 MARY DEFREITAS HAL TEITELBAUM 2015-10-06
501 2013-01-01 MARY DEFREITAS HAL TEITELBAUM 2014-07-29
501 2012-01-01 MARY DEFREITAS HAL TEITELBAUM 2013-09-09
501 2011-01-01 MARY DEFREITAS HAL TEITELBAUM 2012-10-15
501 2010-01-01 MARY DEFREITAS HAL TEITELBAUM 2011-10-28
501 2009-01-01 MARY DEFREITAS MARY DEFREITAS 2010-10-12

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	STEVEN ZENG	2023-10-16
501	2021-01-01	MARY DEFREITAS	2022-09-19
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	MARY DEFREITAS		HAL TEITELBAUM	2018-10-15
501	2016-01-01	MARY DEFREITAS		HAL TEITELBAUM	2017-10-27
501	2015-01-01	MARY DEFREITAS		HAL TEITELBAUM	2016-10-14
501	2014-01-01	MARY DEFREITAS		HAL TEITELBAUM	2015-10-06
501	2013-01-01	MARY DEFREITAS		HAL TEITELBAUM	2014-07-29
501	2012-01-01	MARY DEFREITAS		HAL TEITELBAUM	2013-09-09
501	2011-01-01	MARY DEFREITAS		HAL TEITELBAUM	2012-10-15
501	2010-01-01	MARY DEFREITAS		HAL TEITELBAUM	2011-10-28
501	2009-01-01	MARY DEFREITAS		MARY DEFREITAS	2010-10-12

Plan Statistics for CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN

401k plan membership statisitcs for CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN

Measure Date Value
2022: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 1,921
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 1,660
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 1,660
2021: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 2,682
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 1,921
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 1,921
2020: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 2,847
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 2,682
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 2,682
2019: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,759
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 1,566
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 1,566
2018: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 2,164
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 2,086
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 2,086
2017: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 2,057
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 1,744
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 1,744
2016: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 2,105
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 2,287
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 2,287
2015: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,614
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 2,077
Number of retired or separated participants receiving benefits 2015-01-01 29
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 2,106
2014: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,443
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,608
Number of retired or separated participants receiving benefits 2014-01-01 27
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 1,635
2013: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,100
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,079
Total of all active and inactive participants 2013-01-01 1,079
2012: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,009
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1,097
Total of all active and inactive participants 2012-01-01 1,097
2011: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 973
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,398
Total of all active and inactive participants 2011-01-01 1,398
2010: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 961
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 728
Number of retired or separated participants receiving benefits 2010-01-01 5
Total of all active and inactive participants 2010-01-01 733
2009: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 782
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 961
Number of retired or separated participants receiving benefits 2009-01-01 12
Total of all active and inactive participants 2009-01-01 973

Measure	Date	Value
2022: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	1,921
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	1,660
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	1,660
2021: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	2,682
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	1,921
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	1,921
2020: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	2,847
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	2,682
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	2,682
2019: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,759
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	1,566
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	1,566
2018: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	2,164
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	2,086
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	2,086
2017: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	2,057
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,744
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	1,744
2016: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	2,105
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	2,287
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	2,287
2015: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,614
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	2,077
Number of retired or separated participants receiving benefits	2015-01-01	29
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	2,106
2014: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,443
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,608
Number of retired or separated participants receiving benefits	2014-01-01	27
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	1,635
2013: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,100
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,079
Total of all active and inactive participants	2013-01-01	1,079
2012: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,009
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,097
Total of all active and inactive participants	2012-01-01	1,097
2011: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	973
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,398
Total of all active and inactive participants	2011-01-01	1,398
2010: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	961
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	728
Number of retired or separated participants receiving benefits	2010-01-01	5
Total of all active and inactive participants	2010-01-01	733
2009: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	782
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	961
Number of retired or separated participants receiving benefits	2009-01-01	12
Total of all active and inactive participants	2009-01-01	973

Form 5500 Responses for CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN

2022: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	Yes
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: CRYSTAL RUN HEALTHCARE LLP HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	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

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

Policy contract number

720471

Policy instance

Insurance contract or identification number	720471
Number of Individuals Covered	2795
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $528,901
Total amount of fees paid to insurance company	USD $38,522
Are there contracts with allocated funds for individual policies?	0
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	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,299,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $528,901
Amount paid for insurance broker fees	38522
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

5-09129

Policy instance

Insurance contract or identification number	5-09129
Number of Individuals Covered	62
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,425
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $104,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,937
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	46
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $545
Total amount of fees paid to insurance company	USD $2,485
Are there contracts with allocated funds for individual policies?	0
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
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 $104,076
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	1893
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

000000676776

Policy instance

Insurance contract or identification number	000000676776
Number of Individuals Covered	586
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $20,745
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	OTHER (SPECIFY) DISEASE
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 $254,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,745
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
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	61
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,235
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	OTHER (VOLUNTARY SUPPLEMENTAL INSUR
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 $51,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,064
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

876687

Policy instance

Insurance contract or identification number	876687
Number of Individuals Covered	2513
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $12,363
Total amount of fees paid to insurance company	USD $10,454
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	NYS MANDATED DISABILITY INSURANCE
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 $836,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,363
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

205871

Policy instance

Insurance contract or identification number	205871
Number of Individuals Covered	590
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $54,391
Total amount of fees paid to insurance company	USD $4,533
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $362,605
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,391
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

000000910237

Policy instance

Insurance contract or identification number	000000910237
Number of Individuals Covered	836
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $107,066
Total amount of fees paid to insurance company	USD $7,740
Are there contracts with allocated funds for individual policies?	0
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	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $619,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $92,877
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

720471

Policy instance

Insurance contract or identification number	720471
Number of Individuals Covered	2835
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $531,136
Total amount of fees paid to insurance company	USD $108,874
Are there contracts with allocated funds for individual policies?	0
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	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,315,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $312,598
Amount paid for insurance broker fees	108874
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

000000676776

Policy instance

Insurance contract or identification number	000000676776
Number of Individuals Covered	560
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $23,644
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	OTHER (SPECIFY) DISEASE
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 $236,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,644
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
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	65
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,392
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	OTHER (VOLUNTARY SUPPLEMENTAL INSUR
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 $57,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,446
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

876687

Policy instance

Insurance contract or identification number	876687
Number of Individuals Covered	2443
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $21,766
Total amount of fees paid to insurance company	USD $9,950
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	NYS MANDATED DISABILITY INSURANCE
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 $991,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,766
Amount paid for insurance broker fees	3663
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

000000910237

Policy instance

Insurance contract or identification number	000000910237
Number of Individuals Covered	816
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $84,225
Total amount of fees paid to insurance company	USD $5,707
Are there contracts with allocated funds for individual policies?	0
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	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $561,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84,225
Amount paid for insurance broker fees	1966
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

5-09129

Policy instance

Insurance contract or identification number	5-09129
Number of Individuals Covered	62
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,615
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $95,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,792
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	46
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $648
Total amount of fees paid to insurance company	USD $2,317
Are there contracts with allocated funds for individual policies?	0
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
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 $95,260
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	1749
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

205871

Policy instance

Insurance contract or identification number	205871
Number of Individuals Covered	566
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $52,380
Total amount of fees paid to insurance company	USD $3,556
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $349,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,380
Amount paid for insurance broker fees	1212
Additional information about fees paid to insurance broker	AGENT/BROKER COMPENSATION
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	75
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,229
Total amount of fees paid to insurance company	USD $37
Other welfare benefits provided	OTHER (VOLUNTARY SUPPLEMENTAL INSUR
Welfare Benefit Premiums Paid to Carrier	USD $34,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,515
Amount paid for insurance broker fees	22
Additional information about fees paid to insurance broker	OTHER SERVICING
Insurance broker organization code?	3

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

Policy contract number

720471

Policy instance

Insurance contract or identification number	720471
Number of Individuals Covered	2682
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $494,221
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,287,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $494,221
Insurance broker organization code?	3

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	4
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $552
Total amount of fees paid to insurance company	USD $171
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $222
Amount paid for insurance broker fees	94
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

000000676776

Policy instance

Insurance contract or identification number	000000676776
Number of Individuals Covered	573
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $25,282
Other welfare benefits provided	OTHER (SPECIFY) DISEASE
Welfare Benefit Premiums Paid to Carrier	USD $264,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,282
Insurance broker organization code?	3

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

Policy contract number

876687

Policy instance

Insurance contract or identification number	876687
Number of Individuals Covered	2682
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $12,318
Total amount of fees paid to insurance company	USD $3,173
Other welfare benefits provided	NYS MANDATED DISABILITY INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $500,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,318
Amount paid for insurance broker fees	3173
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	46
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $425
Total amount of fees paid to insurance company	USD $2,141
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $212
Amount paid for insurance broker fees	1711
Additional information about fees paid to insurance broker	PERSISTENCY FEES OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

205871

Policy instance

Insurance contract or identification number	205871
Number of Individuals Covered	544
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $50,010
Total amount of fees paid to insurance company	USD $2,501
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $333,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,010
Amount paid for insurance broker fees	2501
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

000000910237

Policy instance

Insurance contract or identification number	000000910237
Number of Individuals Covered	800
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $88,823
Total amount of fees paid to insurance company	USD $4,441
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $592,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $88,823
Amount paid for insurance broker fees	4441
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

5-09129

Policy instance

Insurance contract or identification number	5-09129
Number of Individuals Covered	60
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SERVICE FEE

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

Policy contract number

910237

Policy instance

Insurance contract or identification number	910237
Number of Individuals Covered	917
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $87,118
Total amount of fees paid to insurance company	USD $4,168
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $555,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $87,118
Amount paid for insurance broker fees	4168
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

205871

Policy instance

Insurance contract or identification number	205871
Number of Individuals Covered	593
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $45,212
Total amount of fees paid to insurance company	USD $2,261
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $301,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,212
Amount paid for insurance broker fees	2261
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	47
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $87,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	OTHER COMPENSATION PERSISTENCY FEES
Insurance broker organization code?	3

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

Policy contract number

CR15318

Policy instance

Insurance contract or identification number	CR15318
Number of Individuals Covered	2961
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $641,709
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,166,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $641,709
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

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

Policy contract number

876687

Policy instance

Insurance contract or identification number	876687
Number of Individuals Covered	2549
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $13,318
Total amount of fees paid to insurance company	USD $3,673
Other welfare benefits provided	NYS MANDATED DISBILITY INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $507,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,318
Amount paid for insurance broker fees	3673
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
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	58
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,495
Total amount of fees paid to insurance company	USD $133
Other welfare benefits provided	OTHER (VOLUNTARY SUPPLEMENTAL INSUR
Welfare Benefit Premiums Paid to Carrier	USD $33,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,194
Amount paid for insurance broker fees	30
Additional information about fees paid to insurance broker	OTHER SERVICING
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

676776 0001

Policy instance

Insurance contract or identification number	676776 0001
Number of Individuals Covered	792
Insurance policy start date	2019-04-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $10,412
Other welfare benefits provided	OTHER (SPECIFY) GRP ACC VOL
Welfare Benefit Premiums Paid to Carrier	USD $102,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,412
Insurance broker organization code?	3

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

10915

Policy instance

Insurance contract or identification number	10915
Number of Individuals Covered	2888
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $63,405
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,268,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63,405
Insurance broker organization code?	3

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	MH982022
Number of Individuals Covered	247
Insurance policy start date	2004-01-01
Insurance policy end date	2004-12-31
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	ACCIDENTAL DEATH & DISMEMBERMENT
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 $59,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Total amount of commissions paid to insurance broker	USD $587
Total amount of fees paid to insurance company	USD $1,958
Commission paid to Insurance Broker	USD $283
Amount paid for insurance broker fees	1539
Additional information about fees paid to insurance broker	PERSISTENCY FEES OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

720471

Policy instance

Insurance contract or identification number	720471
Number of Individuals Covered	2881
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $6,763
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,268,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,763
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

676776 0003

Policy instance

Insurance contract or identification number	676776 0003
Number of Individuals Covered	36
Insurance policy start date	2019-04-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $564
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $564
Insurance broker organization code?	3

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

Policy contract number

5-09129

Policy instance

Insurance contract or identification number	5-09129
Number of Individuals Covered	60
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,485
Total amount of fees paid to insurance company	USD $16
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,797
Insurance broker organization code?	3
Amount paid for insurance broker fees	8
Additional information about fees paid to insurance broker	SERVICE FEE

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

Policy contract number

910237

Policy instance

Insurance contract or identification number	910237
Number of Individuals Covered	1399
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $84,121
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $585,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84,121
Insurance broker organization code?	3

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

Policy contract number

205871

Policy instance

Insurance contract or identification number	205871
Number of Individuals Covered	125
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $44,578
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $300,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,578
Insurance broker organization code?	3

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	47
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,428
Total amount of fees paid to insurance company	USD $1,935
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $92,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $896
Amount paid for insurance broker fees	1537
Additional information about fees paid to insurance broker	OTHER COMPENSATION PERSISTENCY FEES
Insurance broker organization code?	3

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

Policy contract number

CR15318

Policy instance

Insurance contract or identification number	CR15318
Number of Individuals Covered	3059
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $535,688
Total amount of fees paid to insurance company	USD $225
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,878,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $535,688
Insurance broker organization code?	3
Amount paid for insurance broker fees	225
Additional information about fees paid to insurance broker	BONUS

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

Policy contract number

876687

Policy instance

Insurance contract or identification number	876687
Number of Individuals Covered	2905
Insurance policy start date	2017-10-01
Insurance policy end date	2018-10-01
Total amount of commissions paid to insurance broker	USD $11,501
Other welfare benefits provided	NYS MANDATED DISBILITY INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $330,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,501
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	113
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,551
Total amount of fees paid to insurance company	USD $488
Other welfare benefits provided	OTHER (VOLUNTARY SUPPLEMENTAL INSUR
Welfare Benefit Premiums Paid to Carrier	USD $61,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,445
Amount paid for insurance broker fees	130
Additional information about fees paid to insurance broker	OTHER SERVICING
Insurance broker organization code?	3

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

Policy contract number

R0736868

Policy instance

Insurance contract or identification number	R0736868
Number of Individuals Covered	475
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $6,429
Other welfare benefits provided	OTHER (SPECIFY) GRP ACC VOL
Welfare Benefit Premiums Paid to Carrier	USD $50,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,429
Insurance broker organization code?	3

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

10915

Policy instance

Insurance contract or identification number	10915
Number of Individuals Covered	3000
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $64,404
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,288,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $64,404
Insurance broker organization code?	3

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

Policy contract number

720471

Policy instance

Insurance contract or identification number	720471
Number of Individuals Covered	2652
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $6,077
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $152,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,077
Insurance broker organization code?	3

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	4
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $591
Total amount of fees paid to insurance company	USD $180
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $250
Amount paid for insurance broker fees	103
Additional information about fees paid to insurance broker	PERSISTENCY FEE, OTHER SERVICING
Insurance broker organization code?	3

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

Policy contract number

205870

Policy instance

Insurance contract or identification number	205870
Number of Individuals Covered	395
Insurance policy start date	2017-01-01
Insurance policy end date	2017-04-01
Total amount of commissions paid to insurance broker	USD $757
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $757
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

SECURITY MUTUAL LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 68772 )

Policy contract number

GNY040380-00001

Policy instance

Insurance contract or identification number	GNY040380-00001
Number of Individuals Covered	1340
Insurance policy start date	2017-01-01
Insurance policy end date	2017-09-30
Total amount of commissions paid to insurance broker	USD $11,830
Other welfare benefits provided	NYS MANDATED DISABILITY INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $118,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,830
Insurance broker organization code?	3
Insurance broker name	EMERSON REID LLC

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	148
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $14,440
Total amount of fees paid to insurance company	USD $1,234
Other welfare benefits provided	OTHER (VOLUNTARY SUPPLEMENTAL INSUR
Welfare Benefit Premiums Paid to Carrier	USD $84,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,428
Amount paid for insurance broker fees	529
Additional information about fees paid to insurance broker	OTHER SERVICING
Insurance broker organization code?	3
Insurance broker name	MELISA SCHOFIELD

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	2
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $137
Other welfare benefits provided	OTHER VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47
Insurance broker organization code?	3
Insurance broker name	KEVIN MCCARTHY

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

Policy contract number

0869820

Policy instance

Insurance contract or identification number	0869820
Number of Individuals Covered	2787
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $596,132
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,026,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $596,132
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	47
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,791
Total amount of fees paid to insurance company	USD $1,862
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $906
Amount paid for insurance broker fees	1443
Additional information about fees paid to insurance broker	OTHER COMPENSATION PERSISTENCY FEES
Insurance broker organization code?	3
Insurance broker name	PAUL J BUGBEE

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

Policy contract number

205871

Policy instance

Insurance contract or identification number	205871
Number of Individuals Covered	309
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $43,051
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $280,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,051
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

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

Policy contract number

910237

Policy instance

Insurance contract or identification number	910237
Number of Individuals Covered	432
Insurance policy start date	2017-04-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $65,032
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $431,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65,032
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC.

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

10915

Policy instance

Insurance contract or identification number	10915
Number of Individuals Covered	2989
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $61,707
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,172,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,707
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY, INC

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	47
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $730
Total amount of fees paid to insurance company	USD $183
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $223
Amount paid for insurance broker fees	89
Additional information about fees paid to insurance broker	PERSISTENCY FEE, OTHER SERVICING
Insurance broker organization code?	3
Insurance broker name	ADS AGENCY LLC

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

Policy contract number

720471

Policy instance

Insurance contract or identification number	720471
Number of Individuals Covered	1797
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $154,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0869820

Policy instance

Insurance contract or identification number	0869820
Number of Individuals Covered	2382
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $464,884
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,709,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $464,884
Insurance broker name	COOLING INSURING AGENCY

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

Policy contract number

720807

Policy instance

Insurance contract or identification number	720807
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,403
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,403
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

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

Policy contract number

NFJ3452-0807803

Policy instance

Insurance contract or identification number	NFJ3452-0807803
Number of Individuals Covered	142
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $15,290
Total amount of fees paid to insurance company	USD $653
Other welfare benefits provided	OTHER (VOLUNTARY SUPPLEMENTAL INSUR
Welfare Benefit Premiums Paid to Carrier	USD $61,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,452
Amount paid for insurance broker fees	45
Additional information about fees paid to insurance broker	OTHER SERVICING
Insurance broker organization code?	3
Insurance broker name	JEAN-MARC ARCHER

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

Policy contract number

205871

Policy instance

Insurance contract or identification number	205871
Number of Individuals Covered	541
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $32,195
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $214,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,195
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

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

Policy contract number

720471

Policy instance

Insurance contract or identification number	720471
Number of Individuals Covered	2195
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,106
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,106
Insurance broker organization code?	3
Insurance broker name	COOL INSURANCE AGENCY INC

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

Policy contract number

720805

Policy instance

Insurance contract or identification number	720805
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $25,024
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,024
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

SECURITY MUTUAL LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 68772 )

Policy contract number

GNY040380-00001

Policy instance

Insurance contract or identification number	GNY040380-00001
Number of Individuals Covered	1953
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $21,862
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $218,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,862
Insurance broker organization code?	3
Insurance broker name	EMERSON REID & CO., INC.

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

Policy contract number

000000205870

Policy instance

Insurance contract or identification number	000000205870
Number of Individuals Covered	1362
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $9,887
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $418,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,887
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

10915

Policy instance

Insurance contract or identification number	10915
Number of Individuals Covered	2556
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $48,389
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $967,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,389
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY, INC

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	MH982022
Number of Individuals Covered	209
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $7,582
Total amount of fees paid to insurance company	USD $3,659
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	ACCIDENTAL DEATH & DISMEMBERMENT
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 $67,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,582
Insurance broker organization code?	3
Amount paid for insurance broker fees	3659
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	NM MORRISTOWN NJ

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

Policy contract number

205871

Policy instance

Insurance contract or identification number	205871
Number of Individuals Covered	495
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $28,075
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $187,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,075
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

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

Policy contract number

5-09129

Policy instance

Insurance contract or identification number	5-09129
Number of Individuals Covered	163
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,404
Total amount of fees paid to insurance company	USD $3,256
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,437
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
Insurance broker organization code?	3
Amount paid for insurance broker fees	7
Insurance broker name	AGENT SUPPORT SERVICES - A1067

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

Policy contract number

720805

Policy instance

Insurance contract or identification number	720805
Number of Individuals Covered	1476
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $286,620
Total amount of fees paid to insurance company	USD $200,000
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,303,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $286,620
Amount paid for insurance broker fees	200000
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

SECURITY MUTUAL LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 68772 )

Policy contract number

000040380

Policy instance

Insurance contract or identification number	000040380
Number of Individuals Covered	1589
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $18,198
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $181,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,198
Insurance broker organization code?	3
Insurance broker name	EMERSON REID & CO., INC.

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

Policy contract number

000000205870

Policy instance

Insurance contract or identification number	000000205870
Number of Individuals Covered	764
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,874
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $368,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,874
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

10915

Policy instance

Insurance contract or identification number	10915
Number of Individuals Covered	2121
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $42,614
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $852,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,614
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY, INC

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

Policy contract number

NFJ3452-0807803

Policy instance

Insurance contract or identification number	NFJ3452-0807803
Number of Individuals Covered	115
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,114
Total amount of fees paid to insurance company	USD $185
Other welfare benefits provided	OTHER (VOLUNTARY SUPPLEMENTAL INSUR
Welfare Benefit Premiums Paid to Carrier	USD $41,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,772
Amount paid for insurance broker fees	116
Insurance broker organization code?	3
Insurance broker name	JOYCE P MONGERO

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

Policy contract number

720807

Policy instance

Insurance contract or identification number	720807
Number of Individuals Covered	689
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $69,072
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,821,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $69,072
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

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

Policy contract number

720471

Policy instance

Insurance contract or identification number	720471
Number of Individuals Covered	2017
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $4,279
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $102,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,279
Insurance broker organization code?	3
Insurance broker name	COOL INSURANCE AGENCY INC

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	47
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,843
Total amount of fees paid to insurance company	USD $1,437
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49
Amount paid for insurance broker fees	19
Additional information about fees paid to insurance broker	OTHER SERVICING FEES
Insurance broker organization code?	3
Insurance broker name	SEERY FINANCIAL GROUP LLC

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

Policy contract number

NFJ34

Policy instance

Insurance contract or identification number	NFJ34
Number of Individuals Covered	103
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $15,327
Total amount of fees paid to insurance company	USD $2,744
Other welfare benefits provided	OTHER (VOLUNTARY SUPPLEMENTAL INSUR
Welfare Benefit Premiums Paid to Carrier	USD $62,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,528
Amount paid for insurance broker fees	1373
Insurance broker organization code?	3
Insurance broker name	GREGORY E MEYER

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

Policy contract number

720471

Policy instance

Insurance contract or identification number	720471
Number of Individuals Covered	1301
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $3,858
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $103,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,858
Insurance broker organization code?	3
Insurance broker name	COOL INSURANCE AGENCY INC

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	47
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,543
Total amount of fees paid to insurance company	USD $1,746
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $599
Amount paid for insurance broker fees	127
Additional information about fees paid to insurance broker	OTHER SERVICING FEES
Insurance broker organization code?	3
Insurance broker name	THE NEMEC AGENCY LLC

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

10915

Policy instance

Insurance contract or identification number	10915
Number of Individuals Covered	1902
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $39,817
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $796,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,817
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY, INC

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

Policy contract number

000000205870

Policy instance

Insurance contract or identification number	000000205870
Number of Individuals Covered	731
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,796
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $371,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,796
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

SECURITY MUTUAL LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 68772 )

Policy contract number

000040380

Policy instance

Insurance contract or identification number	000040380
Number of Individuals Covered	1427
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $15,364
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $153,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,364
Insurance broker organization code?	3
Insurance broker name	EMERSON REID & CO., INC.

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

Policy contract number

5-9129

Policy instance

Insurance contract or identification number	5-9129
Number of Individuals Covered	73
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $20,182
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $112,733
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
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

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

Policy contract number

720807

Policy instance

Insurance contract or identification number	720807
Number of Individuals Covered	603
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $55,709
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,244,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,709
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

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

Policy contract number

720805

Policy instance

Insurance contract or identification number	720805
Number of Individuals Covered	1301
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $246,011
Total amount of fees paid to insurance company	USD $80,000
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,094,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $246,011
Amount paid for insurance broker fees	80000
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

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

Policy contract number

205871

Policy instance

Insurance contract or identification number	205871
Number of Individuals Covered	494
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $31,922
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $212,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,922
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	46
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,157
Total amount of fees paid to insurance company	USD $1,549
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $322
Amount paid for insurance broker fees	71
Additional information about fees paid to insurance broker	OTHER SERVICING FEES
Insurance broker organization code?	3
Insurance broker name	OLSON FINANCIAL GROUP LLC

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

10915

Policy instance

Insurance contract or identification number	10915
Number of Individuals Covered	935
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $710,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	3
Insurance broker name	COOL INSURING AGENCY, INC

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

Policy contract number

000000205870

Policy instance

Insurance contract or identification number	000000205870
Number of Individuals Covered	763
Insurance policy start date	2012-04-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $9,775
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $236,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,775
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

048-7446-08

Policy instance

Insurance contract or identification number	048-7446-08
Number of Individuals Covered	640
Insurance policy start date	2012-01-01
Insurance policy end date	2012-04-01
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOL DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $101,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	COOL INSURANCE AGENCY INC

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

Policy contract number

720471

Policy instance

Insurance contract or identification number	720471
Number of Individuals Covered	621
Insurance policy end date	2012-03-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,283
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

205871

Policy instance

Insurance contract or identification number	205871
Number of Individuals Covered	520
Insurance policy start date	2012-04-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $11,834
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $80,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,834
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 )

Policy contract number

20023675

Policy instance

Insurance contract or identification number	20023675
Number of Individuals Covered	1247
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $169,917
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,539,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $169,917
Insurance broker name	COOL INSURING

CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 )

Policy contract number

20023674

Policy instance

Insurance contract or identification number	20023674
Number of Individuals Covered	572
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $103,735
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,834,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $103,735
Insurance broker organization code?	3
Insurance broker name	COOL INSURING AGENCY INC

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

Policy contract number

5-9129

Policy instance

Insurance contract or identification number	5-9129
Number of Individuals Covered	85
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $37,859
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $114,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	55
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,956
Total amount of fees paid to insurance company	USD $1,210
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

407478

Policy instance

Insurance contract or identification number	407478
Number of Individuals Covered	431
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $11,666
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $458,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

410479

Policy instance

Insurance contract or identification number	410479
Number of Individuals Covered	1044
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $138,917
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,267,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

720471

Policy instance

Insurance contract or identification number	720471
Number of Individuals Covered	577
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

048-7446-08

Policy instance

Insurance contract or identification number	048-7446-08
Number of Individuals Covered	192
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $40,910
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOL DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $448,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

10915

Policy instance

Insurance contract or identification number	10915
Number of Individuals Covered	800
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $30,511
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $610,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

407478

Policy instance

Insurance contract or identification number	407478
Number of Individuals Covered	548
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $35,948
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,281,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

7206370 001

Policy instance

Insurance contract or identification number	7206370 001
Number of Individuals Covered	143
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $740,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

7206370 901

Policy instance

Insurance contract or identification number	7206370 901
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

407478

Policy instance

Insurance contract or identification number	407478
Number of Individuals Covered	450
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $71,971
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,387,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

86633

Policy instance

Insurance contract or identification number	86633
Number of Individuals Covered	52
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,086
Total amount of fees paid to insurance company	USD $2,251
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

2544

Policy instance

Insurance contract or identification number	2544
Number of Individuals Covered	726
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $28,468
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $569,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

7206370 900

Policy instance

Insurance contract or identification number	7206370 900
Number of Individuals Covered	4
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

7206370 000

Policy instance

Insurance contract or identification number	7206370 000
Number of Individuals Covered	476
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $93,832
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,641,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

048-7446-00

Policy instance

Insurance contract or identification number	048-7446-00
Number of Individuals Covered	969
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $75,903
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOL DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $468,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5-9129

Policy instance

Insurance contract or identification number	5-9129
Number of Individuals Covered	86
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $28,724
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CRYSTAL RUN HEALTHCARE PHYSICIANS, LLP
Employer identification number (EIN):	133843560
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1995-07-26
Company Identification Number:	1942375
Legal Registered Office Address:	155 CRYSTAL RUN RD MIDDLETOWN United States of America (USA) 10941