401k Plan data: EMPIRE RECYCLING PREMIUM ONLY PLAN plan

EMPIRE RECYCLING PREMIUM ONLY PLAN 401k Plan overview

Plan Name	EMPIRE RECYCLING PREMIUM ONLY PLAN
Plan identification number	501

EMPIRE RECYCLING PREMIUM ONLY 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 Other welfare benefit cover

401k Sponsoring company profile

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

Company Name: EMPIRE RECYCLING CORPORATION

Employer identification number (EIN): 150300260

NAIC Classification: 423930
NAIC Description: Recyclable Material Merchant Wholesalers

Additional information about EMPIRE RECYCLING CORPORATION

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1922-10-20

Company Identification Number: 17804

Legal Registered Office Address: GENESEE & LEE STREETS
PO BOX 514
UTICA
United States of America (USA)
13503

More information about EMPIRE RECYCLING CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPIRE RECYCLING PREMIUM ONLY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 STEVEN R. KOWALSKY 2023-10-06
501 2021-01-01 STEVEN R. KOWALSKY 2022-07-27
501 2020-01-01 STEVEN R. KOWALSKY 2021-09-29
501 2019-01-01 STEVEN R. KOWALSKY 2020-10-13
501 2018-01-01 STEVEN R. KOWALSKY 2019-09-06
501 2017-01-01 EDWARD KOWALSKY
501 2016-01-01 EDWARD KOWALSKY
501 2015-01-01 EDWARD KOWALSKY
501 2014-01-01 EDWARD KOWALSKY
501 2013-01-01 EDWARD KOWALSKY
501 2012-01-01 EDWARD KOWALSKY
501 2011-01-01 EDWARD KOWALSKY
501 2010-01-01 EDWARD KOWALSKY
501 2009-01-01 EDWARD KOWALSKY

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	STEVEN R. KOWALSKY	2023-10-06
501	2021-01-01	STEVEN R. KOWALSKY	2022-07-27
501	2020-01-01	STEVEN R. KOWALSKY	2021-09-29
501	2019-01-01	STEVEN R. KOWALSKY	2020-10-13
501	2018-01-01	STEVEN R. KOWALSKY	2019-09-06
501	2017-01-01	EDWARD KOWALSKY
501	2016-01-01	EDWARD KOWALSKY
501	2015-01-01	EDWARD KOWALSKY
501	2014-01-01	EDWARD KOWALSKY
501	2013-01-01	EDWARD KOWALSKY
501	2012-01-01	EDWARD KOWALSKY
501	2011-01-01	EDWARD KOWALSKY
501	2010-01-01	EDWARD KOWALSKY
501	2009-01-01	EDWARD KOWALSKY

Plan Statistics for EMPIRE RECYCLING PREMIUM ONLY PLAN

401k plan membership statisitcs for EMPIRE RECYCLING PREMIUM ONLY PLAN

Measure Date Value
2022: EMPIRE RECYCLING PREMIUM ONLY PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 166
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 167
Total of all active and inactive participants 2022-01-01 167
2021: EMPIRE RECYCLING PREMIUM ONLY PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 157
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 166
Total of all active and inactive participants 2021-01-01 166
2020: EMPIRE RECYCLING PREMIUM ONLY PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 146
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 157
Total of all active and inactive participants 2020-01-01 157
2019: EMPIRE RECYCLING PREMIUM ONLY PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 162
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 146
Total of all active and inactive participants 2019-01-01 146
2018: EMPIRE RECYCLING PREMIUM ONLY PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 162
Total of all active and inactive participants 2018-01-01 162
2017: EMPIRE RECYCLING PREMIUM ONLY PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 128
Total of all active and inactive participants 2017-01-01 128
Total participants 2017-01-01 128
2016: EMPIRE RECYCLING PREMIUM ONLY PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 123
Total of all active and inactive participants 2016-01-01 123
Total participants 2016-01-01 123
2015: EMPIRE RECYCLING PREMIUM ONLY PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 76
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 123
Total of all active and inactive participants 2015-01-01 123
Total participants 2015-01-01 0
2014: EMPIRE RECYCLING PREMIUM ONLY PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 103
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 76
Total of all active and inactive participants 2014-01-01 76
Total participants 2014-01-01 0
2013: EMPIRE RECYCLING PREMIUM ONLY PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 112
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 103
Total of all active and inactive participants 2013-01-01 103
Total participants 2013-01-01 0
2012: EMPIRE RECYCLING PREMIUM ONLY PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 93
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 112
Total of all active and inactive participants 2012-01-01 112
Total participants 2012-01-01 0
2011: EMPIRE RECYCLING PREMIUM ONLY PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 180
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 93
Total of all active and inactive participants 2011-01-01 93
Total participants 2011-01-01 93
2010: EMPIRE RECYCLING PREMIUM ONLY PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 154
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 180
Total of all active and inactive participants 2010-01-01 180
Total participants 2010-01-01 180
2009: EMPIRE RECYCLING PREMIUM ONLY PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 154
Total of all active and inactive participants 2009-01-01 154
Total participants 2009-01-01 154

Measure	Date	Value
2022: EMPIRE RECYCLING PREMIUM ONLY PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	166
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	167
Total of all active and inactive participants	2022-01-01	167
2021: EMPIRE RECYCLING PREMIUM ONLY PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	157
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	166
Total of all active and inactive participants	2021-01-01	166
2020: EMPIRE RECYCLING PREMIUM ONLY PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	146
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	157
Total of all active and inactive participants	2020-01-01	157
2019: EMPIRE RECYCLING PREMIUM ONLY PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	162
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	146
Total of all active and inactive participants	2019-01-01	146
2018: EMPIRE RECYCLING PREMIUM ONLY PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	162
Total of all active and inactive participants	2018-01-01	162
2017: EMPIRE RECYCLING PREMIUM ONLY PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	128
Total of all active and inactive participants	2017-01-01	128
Total participants	2017-01-01	128
2016: EMPIRE RECYCLING PREMIUM ONLY PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	123
Total of all active and inactive participants	2016-01-01	123
Total participants	2016-01-01	123
2015: EMPIRE RECYCLING PREMIUM ONLY PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	76
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	123
Total of all active and inactive participants	2015-01-01	123
Total participants	2015-01-01	0
2014: EMPIRE RECYCLING PREMIUM ONLY PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	103
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	76
Total of all active and inactive participants	2014-01-01	76
Total participants	2014-01-01	0
2013: EMPIRE RECYCLING PREMIUM ONLY PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	112
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	103
Total of all active and inactive participants	2013-01-01	103
Total participants	2013-01-01	0
2012: EMPIRE RECYCLING PREMIUM ONLY PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	93
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	112
Total of all active and inactive participants	2012-01-01	112
Total participants	2012-01-01	0
2011: EMPIRE RECYCLING PREMIUM ONLY PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	180
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	93
Total of all active and inactive participants	2011-01-01	93
Total participants	2011-01-01	93
2010: EMPIRE RECYCLING PREMIUM ONLY PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	154
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	180
Total of all active and inactive participants	2010-01-01	180
Total participants	2010-01-01	180
2009: EMPIRE RECYCLING PREMIUM ONLY PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	154
Total of all active and inactive participants	2009-01-01	154
Total participants	2009-01-01	154

Form 5500 Responses for EMPIRE RECYCLING PREMIUM ONLY PLAN

2022: EMPIRE RECYCLING PREMIUM ONLY 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 benefit arrangement – Insurance	Yes
2021: EMPIRE RECYCLING PREMIUM ONLY PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: EMPIRE RECYCLING PREMIUM ONLY PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: EMPIRE RECYCLING PREMIUM ONLY PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: EMPIRE RECYCLING PREMIUM ONLY PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: EMPIRE RECYCLING PREMIUM ONLY PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: EMPIRE RECYCLING PREMIUM ONLY PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: EMPIRE RECYCLING PREMIUM ONLY PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: EMPIRE RECYCLING PREMIUM ONLY PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: EMPIRE RECYCLING PREMIUM ONLY PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: EMPIRE RECYCLING PREMIUM ONLY PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: EMPIRE RECYCLING PREMIUM ONLY PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: EMPIRE RECYCLING PREMIUM ONLY PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: EMPIRE RECYCLING PREMIUM ONLY PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

00272200

Policy instance

Insurance contract or identification number	00272200
Number of Individuals Covered	167
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $7,388
Total amount of fees paid to insurance company	USD $2,000
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $92,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,532
Amount paid for insurance broker fees	2000
Additional information about fees paid to insurance broker	NOT SPECIFIED
Insurance broker organization code?	3

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

Policy contract number

E7647258

Policy instance

Insurance contract or identification number	E7647258
Number of Individuals Covered	3
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $70
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $70
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00123404

Policy instance

Insurance contract or identification number	00123404
Number of Individuals Covered	89
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $52,588
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $953,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,588
Insurance broker organization code?	3

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

Policy contract number

E7647258

Policy instance

Insurance contract or identification number	E7647258
Number of Individuals Covered	4
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $89
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $89
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0919751

Policy instance

Insurance contract or identification number	0919751
Number of Individuals Covered	87
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $31,047
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $768,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,047
Insurance broker organization code?	3

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

Policy contract number

00272200

Policy instance

Insurance contract or identification number	00272200
Number of Individuals Covered	166
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,789
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $94,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,389
Insurance broker organization code?	3

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

Policy contract number

00272200

Policy instance

Insurance contract or identification number	00272200
Number of Individuals Covered	36
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $1,837
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,801
Insurance broker organization code?	3

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

Policy contract number

000010083531

Policy instance

Insurance contract or identification number	000010083531
Number of Individuals Covered	157
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $1,430
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $12,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,430
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00089898

Policy instance

Insurance contract or identification number	00089898
Number of Individuals Covered	93
Insurance policy start date	2020-01-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $4,689
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,689
Insurance broker organization code?	3

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

Policy contract number

E7647258

Policy instance

Insurance contract or identification number	E7647258
Number of Individuals Covered	4
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $89
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $89
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0919751

Policy instance

Insurance contract or identification number	0919751
Number of Individuals Covered	84
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $29,961
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $749,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,961
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

503678 0010

Policy instance

Insurance contract or identification number	503678 0010
Number of Individuals Covered	44
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $524
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $524
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

503678 0020

Policy instance

Insurance contract or identification number	503678 0020
Number of Individuals Covered	2
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $13
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13
Insurance broker organization code?	3

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

Policy contract number

00936735

Policy instance

Insurance contract or identification number	00936735
Number of Individuals Covered	96
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,759
Total amount of fees paid to insurance company	USD $788
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,759
Amount paid for insurance broker fees	788
Additional information about fees paid to insurance broker	NOT SPECIFIED
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

503678 0030

Policy instance

Insurance contract or identification number	503678 0030
Number of Individuals Covered	4
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $41
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

503678 0040

Policy instance

Insurance contract or identification number	503678 0040
Number of Individuals Covered	25
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $222
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $222
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

503678 0050

Policy instance

Insurance contract or identification number	503678 0050
Number of Individuals Covered	11
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $56
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56
Insurance broker organization code?	3

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

Policy contract number

E7647258

Policy instance

Insurance contract or identification number	E7647258
Number of Individuals Covered	4
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $96
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $96
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00089898

Policy instance

Insurance contract or identification number	00089898
Number of Individuals Covered	89
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,594
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,594
Insurance broker organization code?	3

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

Policy contract number

000010083531

Policy instance

Insurance contract or identification number	000010083531
Number of Individuals Covered	146
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $1,371
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $12,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,371
Insurance broker organization code?	3

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

Policy contract number

00272200

Policy instance

Insurance contract or identification number	00272200
Number of Individuals Covered	30
Insurance policy start date	2019-10-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $407
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $269
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00122949

Policy instance

Insurance contract or identification number	00122949
Number of Individuals Covered	79
Insurance policy start date	2019-01-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $29,100
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $651,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,100
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

503678 0010

Policy instance

Insurance contract or identification number	503678 0010
Number of Individuals Covered	80
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $833
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $833
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

503678 0020

Policy instance

Insurance contract or identification number	503678 0020
Number of Individuals Covered	6
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $68
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $681
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
Insurance broker organization code?	3

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

Policy contract number

00936735

Policy instance

Insurance contract or identification number	00936735
Number of Individuals Covered	81
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,606
Total amount of fees paid to insurance company	USD $202
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,755
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
Amount paid for insurance broker fees	202
Additional information about fees paid to insurance broker	GENERAL FEES
Insurance broker organization code?	3

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

Policy contract number

E7647258

Policy instance

Insurance contract or identification number	E7647258
Number of Individuals Covered	4
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $93
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $93
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

408403

Policy instance

Insurance contract or identification number	408403
Number of Individuals Covered	88
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,519
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,519
Insurance broker organization code?	3

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

Policy contract number

000010083531

Policy instance

Insurance contract or identification number	000010083531
Number of Individuals Covered	144
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $1,276
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $10,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,276
Insurance broker organization code?	3

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

Policy contract number

00272200

Policy instance

Insurance contract or identification number	00272200
Number of Individuals Covered	27
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,531
Total amount of fees paid to insurance company	USD $361
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,501
Amount paid for insurance broker fees	361
Additional information about fees paid to insurance broker	GENERAL FEES
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00122949

Policy instance

Insurance contract or identification number	00122949
Number of Individuals Covered	162
Insurance policy start date	2018-01-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $34,587
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $676,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,587
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

503678 0010

Policy instance

Insurance contract or identification number	503678 0010
Number of Individuals Covered	65
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $641
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $641
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

503678 0020

Policy instance

Insurance contract or identification number	503678 0020
Number of Individuals Covered	10
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $92
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $92
Insurance broker organization code?	3

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

Policy contract number

417006-0001

Policy instance

Insurance contract or identification number	417006-0001
Number of Individuals Covered	55
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $13,511
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $334,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,511
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY, INC.

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

503678 0010DVIO

Policy instance

Insurance contract or identification number	503678 0010DVIO
Number of Individuals Covered	54
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $565
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $565
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY INC.

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

503678 0020DVIO

Policy instance

Insurance contract or identification number	503678 0020DVIO
Number of Individuals Covered	11
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $97
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $97
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY INC.

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

Policy contract number

417006-0010

Policy instance

Insurance contract or identification number	417006-0010
Number of Individuals Covered	13
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $3,238
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,238
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY, INC.

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

Policy contract number

E7647258

Policy instance

Insurance contract or identification number	E7647258
Number of Individuals Covered	4
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $93
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $93
Insurance broker organization code?	3
Insurance broker name	MICHAEL D DAMSKY

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

408403

Policy instance

Insurance contract or identification number	408403
Number of Individuals Covered	81
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,301
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,301
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY, INC.

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

Policy contract number

000010083531

Policy instance

Insurance contract or identification number	000010083531
Number of Individuals Covered	128
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $1,202
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $9,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,202
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY, INC.

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

Policy contract number

417006-0003

Policy instance

Insurance contract or identification number	417006-0003
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $69
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $69
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY, INC.

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

Policy contract number

417006-0004

Policy instance

Insurance contract or identification number	417006-0004
Number of Individuals Covered	1
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $216
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $216
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY, INC.

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

Policy contract number

417006-0005

Policy instance

Insurance contract or identification number	417006-0005
Number of Individuals Covered	2
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $702
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $702
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY, INC.

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

Policy contract number

417006-0006

Policy instance

Insurance contract or identification number	417006-0006
Number of Individuals Covered	1
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $347
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $347
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY, INC.

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

Policy contract number

417006-0007

Policy instance

Insurance contract or identification number	417006-0007
Number of Individuals Covered	4
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $859
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $859
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY, INC.

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

Policy contract number

417006-0008

Policy instance

Insurance contract or identification number	417006-0008
Number of Individuals Covered	5
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $1,468
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,468
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY, INC.

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

Policy contract number

417006-0009

Policy instance

Insurance contract or identification number	417006-0009
Number of Individuals Covered	26
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $6,394
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $158,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,394
Insurance broker organization code?	3
Insurance broker name	GILROY, KERNAN & GILROY, INC.

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

Policy contract number

416996

Policy instance

Insurance contract or identification number	416996
Number of Individuals Covered	40
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $6,241
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $169,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,241
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY, INC.

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

Policy contract number

416995

Policy instance

Insurance contract or identification number	416995
Number of Individuals Covered	30
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $3,749
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,541
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
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY

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

Policy contract number

416994

Policy instance

Insurance contract or identification number	416994
Number of Individuals Covered	27
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $5,401
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $146,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,401
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY, INC.

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

Policy contract number

000010083531

Policy instance

Insurance contract or identification number	000010083531
Number of Individuals Covered	123
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,114
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $9,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $723
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY INC.

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

408403

Policy instance

Insurance contract or identification number	408403
Number of Individuals Covered	75
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,074
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,062
Insurance broker organization code?	3
Insurance broker name	NBT MANG INSURANCE AGENCY

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

Policy contract number

E7647258

Policy instance

Insurance contract or identification number	E7647258
Number of Individuals Covered	7
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $155
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $155
Insurance broker organization code?	3
Insurance broker name	MICHAEL D DAMSKY

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

Policy contract number

416997

Policy instance

Insurance contract or identification number	416997
Number of Individuals Covered	12
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $2,495
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,495
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY, INC.

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

Policy contract number

417006

Policy instance

Insurance contract or identification number	417006
Number of Individuals Covered	31
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $3,659
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $100,260
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,659
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY, INC.

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

5036780010DVIO

Policy instance

Insurance contract or identification number	5036780010DVIO
Number of Individuals Covered	49
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $608
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $608
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY, INC.

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

5036780020DVIO

Policy instance

Insurance contract or identification number	5036780020DVIO
Number of Individuals Covered	8
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $75
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $75
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY, INC.

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

Policy contract number

E7647258

Policy instance

Insurance contract or identification number	E7647258
Number of Individuals Covered	7
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $155
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $155
Insurance broker organization code?	3
Insurance broker name	MICHAEL D DAMSKY

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

408403

Policy instance

Insurance contract or identification number	408403
Number of Individuals Covered	76
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,044
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,807
Insurance broker organization code?	3
Insurance broker name	ENV INSURANCE AGENCY, LLC

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00015032

Policy instance

Insurance contract or identification number	00015032
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $25,517
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $576,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,538
Insurance broker organization code?	3
Insurance broker name	ENV INSURANCE AGENCY, LLC

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

Policy contract number

E7647258

Policy instance

Insurance contract or identification number	E7647258
Number of Individuals Covered	7
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $155
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $155
Insurance broker organization code?	3
Insurance broker name	MICHAEL D. DAMSKY

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

ULPALLMRP00422

Policy instance

Insurance contract or identification number	ULPALLMRP00422
Number of Individuals Covered	103
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $47,546
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $904,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,546
Insurance broker organization code?	3
Insurance broker name	ENV INSURANCE AGENCY, LLC

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

ULPALLMRP00422

Policy instance

Insurance contract or identification number	ULPALLMRP00422
Number of Individuals Covered	116
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,719
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,719
Insurance broker organization code?	3
Insurance broker name	ENV INSURANCE AGENCY, LLC

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

ULPALLMRP00422

Policy instance

Insurance contract or identification number	ULPALLMRP00422
Number of Individuals Covered	112
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $41,979
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $790,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,979
Insurance broker organization code?	3
Insurance broker name	ENV INSURANCE AGENCY, LLC

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

Policy contract number

000010083531

Policy instance

Insurance contract or identification number	000010083531
Number of Individuals Covered	162
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,111
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,111
Insurance broker name	BOUCHEY & CLARKE BENEFITS INC

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

Policy contract number

000010083531

Policy instance

Insurance contract or identification number	000010083531
Number of Individuals Covered	127
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $841
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,642
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

ULPALLMRP00422

Policy instance

Insurance contract or identification number	ULPALLMRP00422
Number of Individuals Covered	93
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $34,400
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $622,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

ULPALLMRP00422

Policy instance

Insurance contract or identification number	ULPALLMRP00422
Number of Individuals Covered	96
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,763
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

ULPALLMRP00422

Policy instance

Insurance contract or identification number	ULPALLMRP00422
Number of Individuals Covered	180
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,358
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

ULPALLMRP00422

Policy instance

Insurance contract or identification number	ULPALLMRP00422
Number of Individuals Covered	170
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $28,340
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

EMPIRE RECYCLING LLC 401 K PROFIT SHARING PLAN TRUST [EIN = 043530907]

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Company Name:	EMPIRE RECYCLING CORPORATION
Employer identification number (EIN):	150300260
NAIC Classification:	423930
NAIC Description:	Recyclable Material Merchant Wholesalers

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1922-10-20
Company Identification Number:	17804
Legal Registered Office Address:	GENESEE & LEE STREETS PO BOX 514 UTICA United States of America (USA) 13503