MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 401k Plan overview

Plan Name	MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN
Plan identification number	507

MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN Benefits

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

401k Sponsoring company profile

MILBANK LLP has sponsored the creation of one or more 401k plans.

Company Name:	MILBANK LLP
Employer identification number (EIN):	135533689
NAIC Classification:	541110
NAIC Description:	Offices of Lawyers

Additional information about MILBANK LLP

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1999-02-01
Company Identification Number:	2340895
Legal Registered Office Address:	55 HUDSON YARDS NEW YORK United States of America (USA) 10001

More information about MILBANK LLP

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
507	2022-01-01	NAJMUN AMIN	2023-10-11
507	2021-01-01
507	2020-01-01
507	2019-01-01
507	2018-01-01
507	2017-01-01
507	2016-01-01	MATHEW ROSSWOOD
507	2015-01-01	H. J. BHATT
507	2014-01-01	NORMA EDMISTON
507	2013-01-01	NORMA EDMISTON
507	2012-01-01	STEVEN GAMCSIK
507	2011-01-01	STEVEN GAMCSIK
507	2010-01-01	STEVEN GAMCSIK		JOEL KRASNOW	2011-07-04
507	2009-01-01	STEVEN GAMCSIK		JOEL KRASNOW	2010-10-08

Plan Statistics for MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN

401k plan membership statisitcs for MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN

Measure	Date	Value
2022: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	1,188
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	1,099
Number of retired or separated participants receiving benefits	2022-01-01	169
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	1,268
Number of employers contributing to the scheme	2022-01-01	0
2021: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	1,189
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	1,065
Number of retired or separated participants receiving benefits	2021-01-01	123
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	1,188
2020: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	1,163
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,049
Number of retired or separated participants receiving benefits	2020-01-01	140
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	1,189
2019: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,014
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	1,047
Number of retired or separated participants receiving benefits	2019-01-01	116
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	1,163
2018: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	999
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,009
Number of retired or separated participants receiving benefits	2018-01-01	135
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	1,144
2017: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	973
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	994
Number of retired or separated participants receiving benefits	2017-01-01	132
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	1,126
2016: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	931
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	944
Number of retired or separated participants receiving benefits	2016-01-01	154
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	1,098
2015: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	914
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	870
Number of retired or separated participants receiving benefits	2015-01-01	133
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	1,003
2014: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	907
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	796
Number of retired or separated participants receiving benefits	2014-01-01	118
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	914
2013: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	786
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	792
Number of retired or separated participants receiving benefits	2013-01-01	115
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	907
2012: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	845
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	764
Number of retired or separated participants receiving benefits	2012-01-01	81
Total of all active and inactive participants	2012-01-01	845
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	13
Total participants	2012-01-01	858
2011: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	828
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	847
Number of retired or separated participants receiving benefits	2011-01-01	105
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	952
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	952
2010: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	824
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	801
Number of retired or separated participants receiving benefits	2010-01-01	104
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	905
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	905
2009: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	966
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	717
Number of retired or separated participants receiving benefits	2009-01-01	107
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	824
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	824

Form 5500 Responses for MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN

2022: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL 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 funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	First time form 5500 has been submitted	Yes
2012-01-01	Submission has been amended	Yes
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	First time form 5500 has been submitted	Yes
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	First time form 5500 has been submitted	Yes
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: MILBANK, TWEED, HADLEY & MCCLOY COMPREHENSIVE MEDICAL PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	First time form 5500 has been submitted	Yes
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	2
Insurance contract or identification number 107165 Number of Individuals Covered 36 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $45 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $210,990 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 45 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3328951
Policy instance	1
Insurance contract or identification number 3328951 Number of Individuals Covered 1294 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid in cash? Yes Welfare Benefit Premiums Paid to Carrier USD $65,988 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	143804
Policy instance	9
Insurance contract or identification number 143804 Number of Individuals Covered 1087 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $31,565 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $804,049 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,943 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
CURALINC HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	3081
Policy instance	3
Insurance contract or identification number 3081 Number of Individuals Covered 872 Insurance policy start date 2022-07-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $7,272 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	511A
Policy instance	4
Insurance contract or identification number 511A Number of Individuals Covered 42 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $51,409 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $642,583 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $51,409 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract number	N18154146
Policy instance	5
Insurance contract or identification number N18154146 Number of Individuals Covered 872 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $4,235 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $21,175 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $4,235 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )
Policy contract number	G8114
Policy instance	6
Insurance contract or identification number G8114 Number of Individuals Covered 11 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $46,391 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	222424
Policy instance	7
Insurance contract or identification number 222424 Number of Individuals Covered 1228 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $33,642 Total amount of fees paid to insurance company USD $24,861 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 Welfare Benefit Premiums Paid to Carrier USD $1,243,052 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,642 Amount paid for insurance broker fees 24861 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	98999151001
Policy instance	8
Insurance contract or identification number 98999151001 Number of Individuals Covered 1172 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $3,749 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $75,267 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,749 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )
Policy contract number	G8114
Policy instance	5
Insurance contract or identification number G8114 Number of Individuals Covered 15 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $56,351 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	222424 0001
Policy instance	4
Insurance contract or identification number 222424 0001 Number of Individuals Covered 1058 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $18,610 Total amount of fees paid to insurance company USD $21,221 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,061,040 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,610 Amount paid for insurance broker fees 21221 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATIOIN PAID Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0144395
Policy instance	3
Insurance contract or identification number 0144395 Number of Individuals Covered 726 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $24,715 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $735,215 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,329 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3328951
Policy instance	2
Insurance contract or identification number 3328951 Number of Individuals Covered 1276 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Other welfare benefits provided PREPAID DENTAL Were dividends or retroactive rate refunds paid in cash? Yes Welfare Benefit Premiums Paid to Carrier USD $72,372 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	98996751001
Policy instance	1
Insurance contract or identification number 98996751001 Number of Individuals Covered 381 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,097 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $20,251 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,095 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00511A
Policy instance	6
Insurance contract or identification number 00511A Number of Individuals Covered 25 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $522,056 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143804
Policy instance	7
Insurance contract or identification number 0143804 Number of Individuals Covered 1056 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $4,822 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided ADD Welfare Benefit Premiums Paid to Carrier USD $91,760 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,822 Insurance broker organization code? 3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	98999151001
Policy instance	13
Insurance contract or identification number 98999151001 Number of Individuals Covered 696 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $2,649 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $48,520 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,645 Insurance broker organization code? 3 Amount paid for insurance broker fees 0
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	99016201001
Policy instance	9
Insurance contract or identification number 99016201001 Number of Individuals Covered 45 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $174 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,502 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $174 Insurance broker organization code? 3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	99016121001
Policy instance	10
Insurance contract or identification number 99016121001 Number of Individuals Covered 5 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $24 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $438 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24 Insurance broker organization code? 3
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )
Policy contract number	474108
Policy instance	11
Insurance contract or identification number 474108 Number of Individuals Covered 213 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $14,325 Total amount of fees paid to insurance company USD $2,865 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $143,246 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,325 Amount paid for insurance broker fees 2865 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract number	N18154146
Policy instance	12
Insurance contract or identification number N18154146 Number of Individuals Covered 1018 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $4,235 Total amount of fees paid to insurance company USD $875 Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $21,175 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,235 Amount paid for insurance broker fees 875 Additional information about fees paid to insurance broker CONTINGENT COMMISSION Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	8
Insurance contract or identification number 107165 Number of Individuals Covered 28 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $235,509 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	GTP0009129448-B
Policy instance	5
Insurance contract or identification number GTP0009129448-B Number of Individuals Covered 1049 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $3,629 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $18,147 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,629 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )
Policy contract number	222422
Policy instance	4
Insurance contract or identification number 222422 Number of Individuals Covered 647 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $7,637 Total amount of fees paid to insurance company USD $4,364 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $218,201 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,637 Amount paid for insurance broker fees 4364 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3328951
Policy instance	2
Insurance contract or identification number 3328951 Number of Individuals Covered 1269 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Other welfare benefits provided PREPAID DENTAL Welfare Benefit Premiums Paid to Carrier USD $65,382 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	98996751001
Policy instance	1
Insurance contract or identification number 98996751001 Number of Individuals Covered 1119 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $3,600 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $72,571 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,600 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )
Policy contract number	G8114
Policy instance	6
Insurance contract or identification number G8114 Number of Individuals Covered 23 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $77,859 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00511A
Policy instance	7
Insurance contract or identification number 00511A Number of Individuals Covered 31 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $31,140 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $390,364 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $31,140 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143804
Policy instance	8
Insurance contract or identification number 0143804 Number of Individuals Covered 1033 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $3,611 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided ADD Welfare Benefit Premiums Paid to Carrier USD $89,043 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,611 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	9
Insurance contract or identification number 107165 Number of Individuals Covered 45 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $242,175 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	222424
Policy instance	10
Insurance contract or identification number 222424 Number of Individuals Covered 1063 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $19,485 Total amount of fees paid to insurance company USD $22,969 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,059,208 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,485 Amount paid for insurance broker fees 22969 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	474108
Policy instance	11
Insurance contract or identification number 474108 Number of Individuals Covered 230 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $15,464 Total amount of fees paid to insurance company USD $5,654 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $143,820 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,464 Amount paid for insurance broker fees 5654 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0144395
Policy instance	3
Insurance contract or identification number 0144395 Number of Individuals Covered 714 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $22,203 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $728,867 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,850 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	GTP0009129448-B
Policy instance	5
Insurance contract or identification number GTP0009129448-B Number of Individuals Covered 1047 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $3,363 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $16,816 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,363 Insurance broker organization code? 3
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )
Policy contract number	222422
Policy instance	4
Insurance contract or identification number 222422 Number of Individuals Covered 638 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $5,576 Total amount of fees paid to insurance company USD $3,440 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $159,327 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,576 Amount paid for insurance broker fees 3440 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0144395
Policy instance	3
Insurance contract or identification number 0144395 Number of Individuals Covered 686 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $19,153 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $682,657 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,091 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3328951
Policy instance	2
Insurance contract or identification number 3328951 Number of Individuals Covered 1250 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $143 Dental Insurance Welfare Benefit Yes Other welfare benefits provided PREPAID DENTAL Were dividends or retroactive rate refunds paid in cash? Yes Welfare Benefit Premiums Paid to Carrier USD $63,018 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 143 Additional information about fees paid to insurance broker SERVICE/GEN. AGENT FEES Insurance broker organization code? 3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	98996751001
Policy instance	1
Insurance contract or identification number 98996751001 Number of Individuals Covered 1047 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $3,408 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $68,065 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,412 Insurance broker organization code? 3
MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )
Policy contract number	G8114
Policy instance	6
Insurance contract or identification number G8114 Number of Individuals Covered 25 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $83,859 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 61360 )
Policy contract number	64722-5
Policy instance	7
Insurance contract or identification number 64722-5 Number of Individuals Covered 329 Insurance policy start date 2019-01-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $12,366 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $91,984 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,366 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00511A
Policy instance	8
Insurance contract or identification number 00511A Number of Individuals Covered 26 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $57,019 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $664,080 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $57,019 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143804
Policy instance	9
Insurance contract or identification number 0143804 Number of Individuals Covered 1041 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $3,550 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided ADD Welfare Benefit Premiums Paid to Carrier USD $86,465 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,550 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	10
Insurance contract or identification number 107165 Number of Individuals Covered 41 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $195,380 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	222424
Policy instance	11
Insurance contract or identification number 222424 Number of Individuals Covered 1361 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $17,580 Total amount of fees paid to insurance company USD $19,159 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,047,205 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,580 Amount paid for insurance broker fees 19159 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	474108
Policy instance	12
Insurance contract or identification number 474108 Number of Individuals Covered 295 Insurance policy start date 2019-07-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $5,432 Total amount of fees paid to insurance company USD $2,716 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $65,140 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,432 Amount paid for insurance broker fees 2716 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	GTP0009129448-B
Policy instance	5
Insurance contract or identification number GTP0009129448-B Number of Individuals Covered 1009 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $4,204 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $16,816 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,204 Insurance broker organization code? 3
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )
Policy contract number	222422
Policy instance	4
Insurance contract or identification number 222422 Number of Individuals Covered 623 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $4,440 Total amount of fees paid to insurance company USD $985 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $126,849 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,440 Amount paid for insurance broker fees 985 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0144395
Policy instance	3
Insurance contract or identification number 0144395 Number of Individuals Covered 656 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $19,438 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $652,925 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,832 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3328951
Policy instance	2
Insurance contract or identification number 3328951 Number of Individuals Covered 1259 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $416 Dental Insurance Welfare Benefit Yes Other welfare benefits provided PREPAID DENTAL Were dividends or retroactive rate refunds paid in cash? Yes Welfare Benefit Premiums Paid to Carrier USD $54,073 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 416 Additional information about fees paid to insurance broker SERVICE/GEN. AGENT FEES Insurance broker organization code? 3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	98996751001
Policy instance	1
Insurance contract or identification number 98996751001 Number of Individuals Covered 1066 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $3,821 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $75,774 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,729 Insurance broker organization code? 3
MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )
Policy contract number	G8114
Policy instance	6
Insurance contract or identification number G8114 Number of Individuals Covered 25 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $77,253 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 61360 )
Policy contract number	64722-5
Policy instance	7
Insurance contract or identification number 64722-5 Number of Individuals Covered 336 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $15,111 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $186,821 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,111 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00511A
Policy instance	8
Insurance contract or identification number 00511A Number of Individuals Covered 36 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $46,004 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $631,562 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $36,694 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143804
Policy instance	9
Insurance contract or identification number 0143804 Number of Individuals Covered 990 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $3,512 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided ADD Welfare Benefit Premiums Paid to Carrier USD $83,042 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,512 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	10
Insurance contract or identification number 107165 Number of Individuals Covered 40 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $213,484 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	222424
Policy instance	11
Insurance contract or identification number 222424 Number of Individuals Covered 1345 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $14,128 Total amount of fees paid to insurance company USD $9,071 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $565,007 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,882 Amount paid for insurance broker fees 3764 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3
CONTINENTAL CASUALTY COMPANY (National Association of Insurance Commissioners NAIC id number: 20443 )
Policy contract number	9491
Policy instance	12
Insurance contract or identification number 9491 Number of Individuals Covered 73 Insurance policy start date 2018-01-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $4,268 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided LONG TERM CARE Welfare Benefit Premiums Paid to Carrier USD $17,479 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,067 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0144395
Policy instance	11
Insurance contract or identification number 0144395 Number of Individuals Covered 648 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $61,516 Total amount of fees paid to insurance company USD $26 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 $608,762 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $57,670 Amount paid for insurance broker fees 26 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name HEATH HOLT
RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 61360 )
Policy contract number	64722-5
Policy instance	12
Insurance contract or identification number 64722-5 Number of Individuals Covered 332 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $20,721 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 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 $182,200 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,721 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	98999151001
Policy instance	13
Insurance contract or identification number 98999151001 Number of Individuals Covered 681 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $2,606 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 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 $56,307 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,606 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	99016121001
Policy instance	14
Insurance contract or identification number 99016121001 Number of Individuals Covered 3 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $17 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 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 $361 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	99016201001
Policy instance	15
Insurance contract or identification number 99016201001 Number of Individuals Covered 5 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $49 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 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 $1,059 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 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0143804
Policy instance	10
Insurance contract or identification number 0143804 Number of Individuals Covered 994 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $3,888 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 Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND 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 $83,230 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,888 Insurance broker organization code? 3 Insurance broker name ANDREW RUBIN
MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )
Policy contract number	G8114
Policy instance	9
Insurance contract or identification number G8114 Number of Individuals Covered 25 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $2,626 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 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 $70,591 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,626 Insurance broker organization code? 3 Insurance broker name AXA NETWORK LLC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	8
Insurance contract or identification number 107165 Number of Individuals Covered 41 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 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 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 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 $246,749 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number	GTP0009129448-A
Policy instance	1
Insurance contract or identification number GTP0009129448-A Number of Individuals Covered 994 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $2,644 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 Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT 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 $10,576 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,644 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00511A
Policy instance	2
Insurance contract or identification number 00511A Number of Individuals Covered 36 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $44,406 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 Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No 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 $603,736 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $44,406 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3328951
Policy instance	3
Insurance contract or identification number 3328951 Number of Individuals Covered 1304 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $580 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 Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? Yes Were dividends or retroactive rate refunds paid as a credit? Yes Welfare Benefit Premiums Paid to Carrier USD $56,801 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 580 Additional information about fees paid to insurance broker SERVICE/GEN.AGENT FEES Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
CONTINENTAL CASUALTY COMPANY (National Association of Insurance Commissioners NAIC id number: 20443 )
Policy contract number	9491
Policy instance	4
Insurance contract or identification number 9491 Number of Individuals Covered 78 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $3,914 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 LONG TERM CARE 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 $77,806 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,914 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	98996751001
Policy instance	5
Insurance contract or identification number 98996751001 Number of Individuals Covered 385 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,138 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 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 $24,692 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,138 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )
Policy contract number	222424
Policy instance	6
Insurance contract or identification number 222424 Number of Individuals Covered 1221 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $13,193 Total amount of fees paid to insurance company USD $6,491 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 $567,122 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,193 Amount paid for insurance broker fees 6491 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )
Policy contract number	1003530000
Policy instance	7
Insurance contract or identification number 1003530000 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 $763 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 Yes 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 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 $21,332 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $763 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS LLC
HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )
Policy contract number	1003530 000
Policy instance	7
Insurance contract or identification number 1003530 000 Number of Individuals Covered 11 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 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 Yes 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 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 $87,616 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,315 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	9901620
Policy instance	6
Insurance contract or identification number 9901620 Number of Individuals Covered 3 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 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 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 $205 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	9901612
Policy instance	5
Insurance contract or identification number 9901612 Number of Individuals Covered 4 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 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 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 $219 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	9899915
Policy instance	4
Insurance contract or identification number 9899915 Number of Individuals Covered 673 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 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 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 $47,136 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	9899675
Policy instance	3
Insurance contract or identification number 9899675 Number of Individuals Covered 386 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 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 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 $21,414 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	376416
Policy instance	2
Insurance contract or identification number 376416 Number of Individuals Covered 1700 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 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 Yes 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 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 $12,729,056 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $81,416 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00511A
Policy instance	1
Insurance contract or identification number 00511A Number of Individuals Covered 47 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $52,732 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 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 $659,145 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $52,732 Insurance broker organization code? 3 Insurance broker name J AND H MARSH AND MC LENNAN
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	8
Insurance contract or identification number 107165 Number of Individuals Covered 29 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 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 Yes 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 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 $128,990 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	9899915
Policy instance	8
Insurance contract or identification number 9899915 Number of Individuals Covered 628 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $44,526 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	9901620
Policy instance	7
Insurance contract or identification number 9901620 Number of Individuals Covered 1 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $52 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	9901612
Policy instance	6
Insurance contract or identification number 9901612 Number of Individuals Covered 3 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $260 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number	9899675
Policy instance	5
Insurance contract or identification number 9899675 Number of Individuals Covered 434 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $23,105 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	376416
Policy instance	4
Insurance contract or identification number 376416 Number of Individuals Covered 1659 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $78,232 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 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 $11,902,459 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $78,232 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )
Policy contract number	1003530 000
Policy instance	3
Insurance contract or identification number 1003530 000 Number of Individuals Covered 12 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $3,806 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 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 $102,738 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,806 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00511A
Policy instance	2
Insurance contract or identification number 00511A Number of Individuals Covered 41 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $54,449 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 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 $678,018 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $54,449 Insurance broker organization code? 3 Insurance broker name J AND H MARSH AND MC LENNAN
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	1
Insurance contract or identification number 107165 Number of Individuals Covered 30 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 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 $132,082 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	00511A
Policy instance	3
Insurance contract or identification number 00511A Number of Individuals Covered 45 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $39,228 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 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 $515,873 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $39,228 Insurance broker organization code? 3 Insurance broker name J AND H MARSH AND MC LENNAN
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9770173
Policy instance	8
Insurance contract or identification number 9770173 Number of Individuals Covered 8 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $26 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $493 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $26 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9768037
Policy instance	7
Insurance contract or identification number 9768037 Number of Individuals Covered 598 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $2,306 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $39,643 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,306 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number	376416
Policy instance	6
Insurance contract or identification number 376416 Number of Individuals Covered 1646 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $76,188 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 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 $12,264,227 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $76,188 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )
Policy contract number	1003530 000
Policy instance	4
Insurance contract or identification number 1003530 000 Number of Individuals Covered 17 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $4,663 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $126,192 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,663 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	2
Insurance contract or identification number 107165 Number of Individuals Covered 29 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit 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 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 $125,588 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9770165
Policy instance	1
Insurance contract or identification number 9770165 Number of Individuals Covered 3 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $107 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,122 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $107 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9768029
Policy instance	5
Insurance contract or identification number 9768029 Number of Individuals Covered 426 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $1,285 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,082 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,285 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	2
Insurance contract or identification number 107165 Number of Individuals Covered 28 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $123,462 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	1003530 000
Policy instance	3
Insurance contract or identification number 1003530 000 Number of Individuals Covered 15 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $5,630 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $140,766 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9770165
Policy instance	4
Insurance contract or identification number 9770165 Number of Individuals Covered 1 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $5 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $121 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9768037
Policy instance	5
Insurance contract or identification number 9768037 Number of Individuals Covered 566 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $1,936 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $33,526 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9768029
Policy instance	7
Insurance contract or identification number 9768029 Number of Individuals Covered 426 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $1,329 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $21,917 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	00511A
Policy instance	8
Insurance contract or identification number 00511A Number of Individuals Covered 46 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $39,598 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $544,152 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9770165
Policy instance	1
Insurance contract or identification number 9770165 Number of Individuals Covered 1 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $5 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $121 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 5 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS-NY,NY
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	00511A
Policy instance	3
Insurance contract or identification number 00511A Number of Individuals Covered 46 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $39,598 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $544,152 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $39,598 Insurance broker organization code? 3 Insurance broker name J&H MARSH & MCLENNAN
HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )
Policy contract number	1003530 000
Policy instance	4
Insurance contract or identification number 1003530 000 Number of Individuals Covered 15 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $5,630 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $140,766 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,630 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9768029
Policy instance	5
Insurance contract or identification number 9768029 Number of Individuals Covered 426 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $1,329 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $21,917 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,329 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS-NY,NY
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number	376416
Policy instance	6
Insurance contract or identification number 376416 Number of Individuals Covered 801 Insurance policy start date 2012-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $71,766 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $10,942,701 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,199 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9768037
Policy instance	7
Insurance contract or identification number 9768037 Number of Individuals Covered 566 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $1,936 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $33,526 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,936 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS-NY, NY
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9770173
Policy instance	8
Insurance contract or identification number 9770173 Number of Individuals Covered 2 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $6 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $134 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 6 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS-NY, NY
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9770173
Policy instance	6
Insurance contract or identification number 9770173 Number of Individuals Covered 2 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $6 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $134 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	376416
Policy instance	1
Insurance contract or identification number 376416 Number of Individuals Covered 801 Insurance policy start date 2012-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $64,679
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number	376416
Policy instance	1
Insurance contract or identification number 376416 Number of Individuals Covered 824 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $64,803 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $10,573,480 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	1003530000
Policy instance	2
Insurance contract or identification number 1003530000 Number of Individuals Covered 15 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $6,177 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $160,771 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	00511A
Policy instance	4
Insurance contract or identification number 00511A Number of Individuals Covered 39 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-01 Total amount of commissions paid to insurance broker USD $38,774 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $452,499 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9768029
Policy instance	5
Insurance contract or identification number 9768029 Number of Individuals Covered 482 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $1,049 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $25,008 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9768037
Policy instance	6
Insurance contract or identification number 9768037 Number of Individuals Covered 480 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $33,622 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $33,622 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	3
Insurance contract or identification number 107165 Number of Individuals Covered 22 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $148,138 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9770173
Policy instance	8
Insurance contract or identification number 9770173 Number of Individuals Covered 7 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $11 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $177 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9770165
Policy instance	7
Insurance contract or identification number 9770165 Number of Individuals Covered 1 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $7 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $150 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	107165
Policy instance	1
Insurance contract or identification number 107165 Number of Individuals Covered 20 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $127,676 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	1003530-000
Policy instance	2
Insurance contract or identification number 1003530-000 Number of Individuals Covered 20 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $6,642 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $166,041 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,642 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name MARSH USA, INC
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9770173
Policy instance	8
Insurance contract or identification number 9770173 Number of Individuals Covered 4 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $25 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $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 $25 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS - NY, NY
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number	376416
Policy instance	4
Insurance contract or identification number 376416 Number of Individuals Covered 806 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $68,730 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,532,581 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $68,730 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS LLC
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9768029
Policy instance	5
Insurance contract or identification number 9768029 Number of Individuals Covered 563 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,355 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $29,528 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,355 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS - NY, NY
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9768037
Policy instance	6
Insurance contract or identification number 9768037 Number of Individuals Covered 347 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,037 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $22,739 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,037 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS - NY, NY
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number	9770165
Policy instance	7
Insurance contract or identification number 9770165 Number of Individuals Covered 3 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $22 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $433 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH & BENEFITS - NY, NY
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	00511A
Policy instance	3
Insurance contract or identification number 00511A Number of Individuals Covered 34 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $33,013 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $418,176 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,013 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name J&H MARSH & MCLENNAN

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