INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 401k Plan overview

Plan Name	INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS
Plan identification number	501

INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS Benefits

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

401k Sponsoring company profile

INVESTORS BANK has sponsored the creation of one or more 401k plans.

Company Name:	INVESTORS BANK
Employer identification number (EIN):	221368780
NAIC Classification:	522120
NAIC Description:	Savings Institutions

Form 5500 Filing Information

Submission information for form 5500 for 401k plan INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	DAWN NALEPA	2023-03-08
501	2021-01-01	DAWN NALEPA	2022-07-22
501	2020-01-01	DAWN NALEPA	2021-10-06
501	2019-01-01	DAWN NALEPA	2020-10-13
501	2018-01-01	DAWN NALEPA	2019-07-31
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	CATHERINE COSSA
501	2011-01-01	CATHERINE COSSA
501	2009-01-01	JOSEPH MASTERSON
501	2009-01-01		2010-09-07

Plan Statistics for INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS

401k plan membership statisitcs for INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS

Measure	Date	Value
2022: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2022 401k membership
Total participants, beginning-of-year	2022-01-01	1,621
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	0
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	0
2021: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2021 401k membership
Total participants, beginning-of-year	2021-01-01	1,794
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	1,621
Number of retired or separated participants receiving benefits	2021-01-01	40
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	1,661
2020: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2020 401k membership
Total participants, beginning-of-year	2020-01-01	1,764
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,749
Number of retired or separated participants receiving benefits	2020-01-01	45
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	1,794
2019: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,902
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	1,764
Number of retired or separated participants receiving benefits	2019-01-01	62
Total of all active and inactive participants	2019-01-01	1,826
2018: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2018 401k membership
Total participants, beginning-of-year	2018-01-01	1,655
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,902
Number of retired or separated participants receiving benefits	2018-01-01	19
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	1,921
2017: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,529
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,655
Number of retired or separated participants receiving benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	1,655
2016: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,760
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,848
Total of all active and inactive participants	2016-01-01	1,848
2015: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,710
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,789
Total of all active and inactive participants	2015-01-01	1,789
2014: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,307
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,647
Number of retired or separated participants receiving benefits	2014-01-01	33
Total of all active and inactive participants	2014-01-01	1,680
2013: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,248
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,255
Number of retired or separated participants receiving benefits	2013-01-01	52
Total of all active and inactive participants	2013-01-01	1,307
2012: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2012 401k membership
Total participants, beginning-of-year	2012-01-01	851
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,023
Number of retired or separated participants receiving benefits	2012-01-01	37
Total of all active and inactive participants	2012-01-01	1,060
2011: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2011 401k membership
Total participants, beginning-of-year	2011-01-01	777
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	851
Number of retired or separated participants receiving benefits	2011-01-01	0
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	851
2009: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2009 401k membership
Total participants, beginning-of-year	2009-01-01	458
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	483
Number of retired or separated participants receiving benefits	2009-01-01	0
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	483

Form 5500 Responses for INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS

2022: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	This submission is the final filing	Yes
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
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: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 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 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: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 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 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: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 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 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: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 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 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: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 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 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: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 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 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: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 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: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 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: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 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: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 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: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: INVESTORS BANK HEALTH AND WELFARE BENEFIT PLANS 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
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

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 752161
Policy instance	7
Insurance contract or identification number LK 752161 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $3,807 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $49,834 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
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	9260443
Policy instance	16
Insurance contract or identification number 9260443 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $1,397 Total amount of fees paid to insurance company USD $367 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $13,779 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,397 Amount paid for insurance broker fees 367 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 968519
Policy instance	1
Insurance contract or identification number OK 968519 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $1,271 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH Welfare Benefit Premiums Paid to Carrier USD $18,829 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,271 Insurance broker organization code? 3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD075387
Policy instance	2
Insurance contract or identification number NYD075387 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $2,975 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $78,853 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,975 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 964814
Policy instance	3
Insurance contract or identification number LK 964814 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $5,629 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $104,950 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,629 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SDJ960587
Policy instance	4
Insurance contract or identification number SDJ960587 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $11,895 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $297,378 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,895 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967008
Policy instance	5
Insurance contract or identification number FLX967008 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $11,897 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $176,245 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,897 Insurance broker organization code? 7
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0314808-SL
Policy instance	6
Insurance contract or identification number 0314808-SL Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Welfare Benefit Premiums Paid to Carrier USD $618,377 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	0200528
Policy instance	8
Insurance contract or identification number 0200528 Number of Individuals Covered 0 Insurance policy start date 2021-07-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $12,231 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $110,809 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,231 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SHD962976
Policy instance	15
Insurance contract or identification number SHD962976 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $23,973 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX969001
Policy instance	14
Insurance contract or identification number FLX969001 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $4,811 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided DEPENDENT LIFE Welfare Benefit Premiums Paid to Carrier USD $71,277 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,811 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK970462
Policy instance	13
Insurance contract or identification number OK970462 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $933 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH Welfare Benefit Premiums Paid to Carrier USD $13,823 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $933 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30093617
Policy instance	12
Insurance contract or identification number 30093617 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $3,025 Total amount of fees paid to insurance company USD $0 Vision 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 $3,025 Insurance broker organization code? 3
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	09570
Policy instance	11
Insurance contract or identification number 09570 Insurance policy start date 2022-01-01 Insurance policy end date 2022-04-30 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 Welfare Benefit Premiums Paid to Carrier USD $2,112,099 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008246461
Policy instance	10
Insurance contract or identification number 0008246461 Number of Individuals Covered 0 Insurance policy start date 2022-01-01 Insurance policy end date 2022-05-01 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 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,501 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	0166586
Policy instance	9
Insurance contract or identification number MR 61055 Number of Individuals Covered 225 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? Yes 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 Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Welfare Benefit Premiums Paid to Carrier USD $86,062 Commission paid to Insurance Broker USD $9,524 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 752161
Policy instance	7
Insurance contract or identification number LK 752161 Number of Individuals Covered 310 Insurance policy start date 2021-03-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $2,777 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $36,548 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,777 Insurance broker organization code? 7
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0314808-SL
Policy instance	6
Insurance contract or identification number 0314808-SL Number of Individuals Covered 1227 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 Welfare Benefit Premiums Paid to Carrier USD $1,997,436 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967008
Policy instance	5
Insurance contract or identification number FLX967008 Number of Individuals Covered 1621 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $12,011 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $179,080 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,011 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SDJ960587
Policy instance	4
Insurance contract or identification number SDJ960587 Number of Individuals Covered 1389 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $15,039 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $375,983 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,039 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 964814
Policy instance	3
Insurance contract or identification number LK 964814 Number of Individuals Covered 1483 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $4,895 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $96,024 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,895 Insurance broker organization code? 7
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD075387
Policy instance	2
Insurance contract or identification number NYD075387 Number of Individuals Covered 310 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $3,252 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $63,105 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,252 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 968519
Policy instance	1
Insurance contract or identification number OK 968519 Number of Individuals Covered 1621 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,303 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH Welfare Benefit Premiums Paid to Carrier USD $19,305 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,303 Insurance broker organization code? 7
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0200528
Policy instance	8
Insurance contract or identification number 0200528 Number of Individuals Covered 661 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $11,552 Total amount of fees paid to insurance company USD $1,059 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $119,335 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,552 Amount paid for insurance broker fees 1059 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0166586
Policy instance	9
Insurance contract or identification number 0166586 Number of Individuals Covered 1201 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $9,232 Total amount of fees paid to insurance company USD $835 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $94,764 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,232 Amount paid for insurance broker fees 835 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008246461
Policy instance	10
Insurance contract or identification number 0008246461 Number of Individuals Covered 28 Insurance policy start date 2021-01-01 Insurance policy end date 2021-07-01 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 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,842 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	09570
Policy instance	11
Insurance contract or identification number 09570 Number of Individuals Covered 2720 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 Welfare Benefit Premiums Paid to Carrier USD $1,522,146 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EXPRESS SCRIPTS, INC. (National Association of Insurance Commissioners NAIC id number: 60025 )
Policy contract number	6343
Policy instance	12
Insurance contract or identification number 6343 Number of Individuals Covered 37 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $10,917 Total amount of fees paid to insurance company USD $0 Welfare Benefit Premiums Paid to Carrier USD $95,933 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,917 Insurance broker organization code? 5
MONUMENTAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 66281 )
Policy contract number	MZ0200635H0000A
Policy instance	13
Insurance contract or identification number MZ0200635H0000A Number of Individuals Covered 40 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $22,677 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Other welfare benefits provided MEDICARE SUPPLEMENTAL Welfare Benefit Premiums Paid to Carrier USD $145,301 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,958 Insurance broker organization code? 5
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30093617
Policy instance	14
Insurance contract or identification number 30093617 Number of Individuals Covered 1308 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $9,974 Total amount of fees paid to insurance company USD $0 Vision 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 $9,974 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK970462
Policy instance	15
Insurance contract or identification number OK970462 Number of Individuals Covered 606 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,160 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH Welfare Benefit Premiums Paid to Carrier USD $17,185 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,160 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX969001
Policy instance	16
Insurance contract or identification number FLX969001 Number of Individuals Covered 175 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $4,593 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided DEPENDENT LIFE Welfare Benefit Premiums Paid to Carrier USD $68,045 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,593 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967008
Policy instance	6
Insurance contract or identification number FLX967008 Number of Individuals Covered 1749 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $32,072 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $478,427 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32,072 Insurance broker organization code? 7
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0314808-SL
Policy instance	7
Insurance contract or identification number 0314808-SL Number of Individuals Covered 1381 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 Welfare Benefit Premiums Paid to Carrier USD $2,567,779 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SDJ960587
Policy instance	5
Insurance contract or identification number SDJ960587 Number of Individuals Covered 1538 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $29,565 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $739,119 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,565 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 964814
Policy instance	4
Insurance contract or identification number LK 964814 Number of Individuals Covered 1633 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $6,598 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $259,843 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,598 Insurance broker organization code? 7
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD075387
Policy instance	3
Insurance contract or identification number NYD075387 Number of Individuals Covered 341 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $3,711 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $76,098 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,711 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 968519
Policy instance	2
Insurance contract or identification number OK 968519 Number of Individuals Covered 1749 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $3,472 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH Welfare Benefit Premiums Paid to Carrier USD $51,433 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,472 Insurance broker organization code? 7
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	IVSL0-001
Policy instance	1
Insurance contract or identification number IVSL0-001 Number of Individuals Covered 1655 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 Other welfare benefits provided EAP Welfare Benefit Premiums Paid to Carrier USD $26,364 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 752161
Policy instance	8
Insurance contract or identification number LK 752161 Number of Individuals Covered 1532 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $3,815 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $57,557 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,815 Insurance broker organization code? 7
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0200528
Policy instance	9
Insurance contract or identification number 0200528 Number of Individuals Covered 607 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $6,942 Total amount of fees paid to insurance company USD $974 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $78,205 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,942 Amount paid for insurance broker fees 974 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0166586
Policy instance	10
Insurance contract or identification number 0166586 Number of Individuals Covered 984 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $6,816 Total amount of fees paid to insurance company USD $1,193 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $72,649 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,816 Amount paid for insurance broker fees 1193 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
EXPRESS SCRIPTS, INC. (National Association of Insurance Commissioners NAIC id number: 60025 )
Policy contract number	6343
Policy instance	13
Insurance contract or identification number 6343 Number of Individuals Covered 38 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $11,041 Total amount of fees paid to insurance company USD $0 Welfare Benefit Premiums Paid to Carrier USD $92,761 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,041 Insurance broker organization code? 5
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX969001
Policy instance	17
Insurance contract or identification number FLX969001 Number of Individuals Covered 128 Insurance policy start date 2020-06-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $6,788 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided DEPENDENT LIFE Welfare Benefit Premiums Paid to Carrier USD $100,560 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,788 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK970462
Policy instance	16
Insurance contract or identification number OK970462 Number of Individuals Covered 609 Insurance policy start date 2020-06-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,136 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH Welfare Benefit Premiums Paid to Carrier USD $16,823 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,136 Insurance broker organization code? 7
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30093617
Policy instance	15
Insurance contract or identification number 30093617 Number of Individuals Covered 1368 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $6,733 Total amount of fees paid to insurance company USD $0 Vision 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 $6,733 Insurance broker organization code? 3
MONUMENTAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 66281 )
Policy contract number	MZ0200635H0000A
Policy instance	14
Insurance contract or identification number MZ0200635H0000A Number of Individuals Covered 42 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $21,944 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Other welfare benefits provided MEDICARE SUPPLEMENTAL Welfare Benefit Premiums Paid to Carrier USD $140,601 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,442 Insurance broker organization code? 5
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	09570
Policy instance	12
Insurance contract or identification number 09570 Number of Individuals Covered 3098 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 Welfare Benefit Premiums Paid to Carrier USD $1,299,175 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008246461
Policy instance	11
Insurance contract or identification number 0008246461 Number of Individuals Covered 54 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 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $14,566 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967008
Policy instance	6
Insurance contract or identification number FLX967008 Number of Individuals Covered 1764 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $41,795 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $619,807 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $41,795 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SDJ960587
Policy instance	5
Insurance contract or identification number SDJ960587 Number of Individuals Covered 1531 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $33,473 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $826,901 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,473 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 964814
Policy instance	4
Insurance contract or identification number LK 964814 Number of Individuals Covered 1764 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $6,860 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $286,027 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,860 Insurance broker organization code? 7
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD075387
Policy instance	3
Insurance contract or identification number NYD075387 Number of Individuals Covered 295 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $3,222 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $69,145 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,222 Insurance broker organization code? 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 968519
Policy instance	2
Insurance contract or identification number OK 968519 Number of Individuals Covered 1764 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $4,708 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH Welfare Benefit Premiums Paid to Carrier USD $75,141 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,708 Insurance broker organization code? 7
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	IVSL0-001
Policy instance	1
Insurance contract or identification number IVSL0-001 Number of Individuals Covered 1655 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 Other welfare benefits provided EAP Welfare Benefit Premiums Paid to Carrier USD $26,364 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0314808-SL
Policy instance	7
Insurance contract or identification number 0314808-SL Number of Individuals Covered 1425 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 Welfare Benefit Premiums Paid to Carrier USD $3,560,725 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 752161
Policy instance	8
Insurance contract or identification number LK 752161 Number of Individuals Covered 1423 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $3,524 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $51,601 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,524 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0166586
Policy instance	10
Insurance contract or identification number 0166586 Number of Individuals Covered 657 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $4,853 Total amount of fees paid to insurance company USD $1,110 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $50,862 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,853 Amount paid for insurance broker fees 1110 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
MONUMENTAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 66281 )
Policy contract number	MZ0200635H0000A
Policy instance	15
Insurance contract or identification number MZ0200635H0000A Number of Individuals Covered 45 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $23,195 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Other welfare benefits provided MEDICARE SUPPLEMENTAL Welfare Benefit Premiums Paid to Carrier USD $148,620 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,322 Insurance broker organization code? 5
EXPRESS SCRIPTS, INC. (National Association of Insurance Commissioners NAIC id number: 60025 )
Policy contract number	6343
Policy instance	14
Insurance contract or identification number 6343 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 $12,152 Total amount of fees paid to insurance company USD $0 Welfare Benefit Premiums Paid to Carrier USD $97,283 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,152 Insurance broker organization code? 5
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	09570
Policy instance	13
Insurance contract or identification number 09570 Number of Individuals Covered 3262 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 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,474,118 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008246461
Policy instance	12
Insurance contract or identification number 0008246461 Number of Individuals Covered 61 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $-5 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 $14,374 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 Insurance broker organization code? 3
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )
Policy contract number	0008246461
Policy instance	11
Insurance contract or identification number 0008246461 Number of Individuals Covered 1 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 $211 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	0200528
Policy instance	9
Insurance contract or identification number 0200528 Number of Individuals Covered 278 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $3,986 Total amount of fees paid to insurance company USD $874 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $41,557 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,986 Amount paid for insurance broker fees 874 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967008
Policy instance	7
Insurance contract or identification number FLX967008 Number of Individuals Covered 1902 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $47,961 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $710,529 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $47,961 Insurance broker organization code? 3
STONEBRIDGE LIFE INSURANCE (National Association of Insurance Commissioners NAIC id number: 65021 )
Policy contract number	S9579090
Policy instance	8
Insurance contract or identification number S9579090 Number of Individuals Covered 43 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $12,473 Total amount of fees paid to insurance company USD $0 Welfare Benefit Premiums Paid to Carrier USD $112,331 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,484 Insurance broker organization code? 5
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0314808-SL
Policy instance	9
Insurance contract or identification number 0314808-SL Number of Individuals Covered 1481 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 Welfare Benefit Premiums Paid to Carrier USD $2,749,229 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 752161
Policy instance	10
Insurance contract or identification number LK 752161 Number of Individuals Covered 1902 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $3,518 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $49,256 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,518 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0200528
Policy instance	11
Insurance contract or identification number 0200528 Number of Individuals Covered 218 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $2,430 Total amount of fees paid to insurance company USD $1,041 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $30,110 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,430 Amount paid for insurance broker fees 1041 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0166586
Policy instance	12
Insurance contract or identification number 0166586 Number of Individuals Covered 494 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $2,776 Total amount of fees paid to insurance company USD $1,347 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $35,069 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,776 Amount paid for insurance broker fees 1347 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )
Policy contract number	0008246461
Policy instance	13
Insurance contract or identification number 0008246461 Number of Individuals Covered 1 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 $727 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008246461
Policy instance	14
Insurance contract or identification number 0008246461 Number of Individuals Covered 70 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $54 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 $23,983 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 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SDJ960587
Policy instance	6
Insurance contract or identification number SDJ960587 Number of Individuals Covered 1680 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $35,051 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $876,271 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $35,051 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 964814
Policy instance	5
Insurance contract or identification number LK 964814 Number of Individuals Covered 1902 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $3,067 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $306,700 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,067 Insurance broker organization code? 3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD075387
Policy instance	4
Insurance contract or identification number NYD075387 Number of Individuals Covered 310 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $4,391 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $62,777 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,391 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 968519
Policy instance	3
Insurance contract or identification number OK 968519 Number of Individuals Covered 1902 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $6,549 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH Welfare Benefit Premiums Paid to Carrier USD $97,021 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,549 Insurance broker organization code? 3
MONUMENTAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 66281 )
Policy contract number	MZ0200635H000A
Policy instance	2
Insurance contract or identification number MZ0200635H000A Number of Individuals Covered 47 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $22,611 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $144,878 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,700 Insurance broker organization code? 3
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	IVSL0-001
Policy instance	1
Insurance contract or identification number IVSL0-001 Number of Individuals Covered 1655 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 Other welfare benefits provided EAP Welfare Benefit Premiums Paid to Carrier USD $43,940 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD075387
Policy instance	4
Insurance contract or identification number NYD075387 Number of Individuals Covered 1940 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $2,664 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $34,276 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,664 Insurance broker organization code? 3 Insurance broker name KATIE CUMMINGS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 968519
Policy instance	3
Insurance contract or identification number OK 968519 Number of Individuals Covered 1940 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $4,754 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL DEATH Welfare Benefit Premiums Paid to Carrier USD $70,433 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,754 Insurance broker organization code? 3 Insurance broker name KATIE CUMMINGS
MONUMENTAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 66281 )
Policy contract number	MZ0200635H000A
Policy instance	2
Insurance contract or identification number MZ0200635H000A Number of Individuals Covered 47 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $22,931 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $146,929 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,137 Insurance broker organization code? 5 Insurance broker name BOLLINGER INC.
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	IVSL0-001
Policy instance	1
Insurance contract or identification number IVSL0-001 Number of Individuals Covered 1655 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 $0 Other welfare benefits provided EAP Welfare Benefit Premiums Paid to Carrier USD $43,940 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 964814
Policy instance	5
Insurance contract or identification number LK 964814 Number of Individuals Covered 1940 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $6,167 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $216,729 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,167 Insurance broker organization code? 3 Insurance broker name KATIE CUMMINGS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	SDJ960587
Policy instance	6
Insurance contract or identification number SDJ960587 Number of Individuals Covered 1940 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $28,475 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $711,880 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,475 Insurance broker organization code? 3 Insurance broker name KATIE CUMMINGS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX967008
Policy instance	7
Insurance contract or identification number FLX967008 Number of Individuals Covered 1940 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $38,829 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $575,238 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $38,829 Insurance broker organization code? 3 Insurance broker name KATIE CUMMINGS
STONEBRIDGE LIFE INSURANCE (National Association of Insurance Commissioners NAIC id number: 65021 )
Policy contract number	S9579090
Policy instance	8
Insurance contract or identification number S9579090 Number of Individuals Covered 42 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $11,682 Total amount of fees paid to insurance company USD $0 Welfare Benefit Premiums Paid to Carrier USD $105,139 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,009 Insurance broker organization code? 5 Insurance broker name BOLLINGER INC.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0314808-SL
Policy instance	9
Insurance contract or identification number 0314808-SL Number of Individuals Covered 1521 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 $0 Welfare Benefit Premiums Paid to Carrier USD $2,365,865 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 752161
Policy instance	10
Insurance contract or identification number LK 752161 Number of Individuals Covered 1940 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,831 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $19,731 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,831 Insurance broker organization code? 3 Insurance broker name KATIE CUMMINGS
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	227263
Policy instance	11
Insurance contract or identification number 227263 Number of Individuals Covered 1781 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $33,391 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $495,962 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,391 Insurance broker organization code? 3 Insurance broker name CUMMINGS, KATHERINE
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	227263
Policy instance	12
Insurance contract or identification number 227263 Number of Individuals Covered 1775 Insurance policy start date 2015-02-01 Insurance policy end date 2016-01-31 Total amount of commissions paid to insurance broker USD $32 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 $6,693 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32 Insurance broker organization code? 3 Insurance broker name CUMMINGS, KATHERINE
MONUMENTAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 66281 )
Policy contract number	MZ091057950000A
Policy instance	13
Insurance contract or identification number MZ091057950000A Number of Individuals Covered 54 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $22,885 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $146,635 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,104 Insurance broker organization code? 5 Insurance broker name BOLLINGER INC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0314808-SL
Policy instance	2
Insurance contract or identification number 0314808-SL Number of Individuals Covered 1350 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Welfare Benefit Premiums Paid to Carrier USD $1,735,303 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	IVSL0-001
Policy instance	10
Insurance contract or identification number IVSL0-001 Number of Individuals Covered 1655 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EAP Welfare Benefit Premiums Paid to Carrier USD $40,770 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008246461
Policy instance	9
Insurance contract or identification number 0008246461 Number of Individuals Covered 87 Insurance policy start date 2015-01-01 Insurance policy end date 2016-01-01 Total amount of commissions paid to insurance broker USD $141 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VB ACIDENT, ISWL STND Welfare Benefit Premiums Paid to Carrier USD $28,466 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $141 Insurance broker organization code? 3 Insurance broker name CUMMINGS, KATHERINE
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )
Policy contract number	0008246461
Policy instance	8
Insurance contract or identification number 0008246461 Number of Individuals Covered 3 Insurance policy start date 2015-01-01 Insurance policy end date 2016-01-01 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VB ACCIDENT, ISWL STND Welfare Benefit Premiums Paid to Carrier USD $752 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	234072
Policy instance	7
Insurance contract or identification number 234072 Number of Individuals Covered 1701 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $5,894 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $145,465 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,894 Insurance broker organization code? 3 Insurance broker name CUMMINGS, KATHERINE
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0314808
Policy instance	3
Insurance contract or identification number 0314808 Number of Individuals Covered 3194 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $11,942 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,596,226 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 11942 Additional information about fees paid to insurance broker 2014/2015 PPP ENGAGEMENT CREDIT Insurance broker organization code? 3 Insurance broker name BOLLINGER INC
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number	823136
Policy instance	5
Insurance contract or identification number 823136 Number of Individuals Covered 257 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $1,707 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided DISABILITY BENEFIT LAW Welfare Benefit Premiums Paid to Carrier USD $24,741 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,707 Insurance broker organization code? 3 Insurance broker name CUMMINGS, KATIE
STERLING LIFE (National Association of Insurance Commissioners NAIC id number: 77399 )
Policy contract number	ENH 4T09
Policy instance	1
Insurance contract or identification number ENH 4T09 Number of Individuals Covered 48 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $13,875 Total amount of fees paid to insurance company USD $0 Welfare Benefit Premiums Paid to Carrier USD $108,507 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,526 Insurance broker organization code? 5 Insurance broker name BOLLINGER INC
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	234073
Policy instance	6
Insurance contract or identification number 234073 Number of Individuals Covered 1569 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $20,887 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $535,970 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,887 Insurance broker organization code? 3 Insurance broker name CUMMINGS, KATHERINE
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000064095705
Policy instance	4
Insurance contract or identification number 000064095705 Number of Individuals Covered 1650 Insurance policy start date 2014-09-21 Insurance policy end date 2015-09-21 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided AD&D Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	227263
Policy instance	13
Insurance contract or identification number 227263 Number of Individuals Covered 1664 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $36,217 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $420,895 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $36,217 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name KATHERINE CUMMINGS
MONUMENTAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 66281 )
Policy contract number	MZ0200635H0000A
Policy instance	2
Insurance contract or identification number MZ0200635H0000A Number of Individuals Covered 54 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $21,619 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $138,522 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,213 Insurance broker organization code? 5 Insurance broker name BOLLINGER INC
STERLING LIFE (National Association of Insurance Commissioners NAIC id number: 77399 )
Policy contract number	S 4802
Policy instance	3
Insurance contract or identification number S 4802 Number of Individuals Covered 48 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $12,109 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $108,844 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,931 Insurance broker organization code? 5 Insurance broker name BOLLINGER INC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0314808-SL
Policy instance	4
Insurance contract or identification number 0314808-SL Number of Individuals Covered 1290 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 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $1,182,489 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000064095705
Policy instance	6
Insurance contract or identification number 000064095705 Number of Individuals Covered 1698 Insurance policy start date 2013-09-21 Insurance policy end date 2014-09-21 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided AD&D Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	234073
Policy instance	8
Insurance contract or identification number 234073 Number of Individuals Covered 1425 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $15,659 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $392,714 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,659 Insurance broker organization code? 3 Insurance broker name KATIE CUMMINGS
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number	823136
Policy instance	7
Insurance contract or identification number 823136 Number of Individuals Covered 234 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $1,147 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided DISABILITY BENEFIT LAW Welfare Benefit Premiums Paid to Carrier USD $17,456 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,147 Insurance broker organization code? 3 Insurance broker name KATIE CUMMINGS
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	234072
Policy instance	9
Insurance contract or identification number 234072 Number of Individuals Covered 1624 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $4,408 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $130,536 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,408 Insurance broker organization code? 3 Insurance broker name KATIE CUMMINGS
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008246461
Policy instance	11
Insurance contract or identification number 0008246461 Number of Individuals Covered 89 Insurance policy start date 2014-01-01 Insurance policy end date 2015-01-01 Total amount of commissions paid to insurance broker USD $308 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided VB ACIDENT, ISWL STND Welfare Benefit Premiums Paid to Carrier USD $24,707 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $308 Insurance broker organization code? 3 Insurance broker name KATHERINE CUMMINGS
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	IVSL0-001
Policy instance	12
Insurance contract or identification number IVSL0-001 Number of Individuals Covered 1058 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 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided EAP Welfare Benefit Premiums Paid to Carrier USD $16,854 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0314808
Policy instance	5
Insurance contract or identification number 0314808 Number of Individuals Covered 3088 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 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,515,979 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	9361
Policy instance	1
Insurance contract or identification number 9361 Number of Individuals Covered 0 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 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes 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	0008246461
Policy instance	10
Insurance contract or identification number 0008246461 Number of Individuals Covered 3 Insurance policy start date 2014-01-01 Insurance policy end date 2015-01-01 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided VB ACCIDENT, ISWL STND Welfare Benefit Premiums Paid to Carrier USD $1,272 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008246461
Policy instance	12
Insurance contract or identification number 0008246461 Number of Individuals Covered 95 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $457 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $27,899 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $457 Amount paid for insurance broker fees 0 Insurance broker name KATHERINE CUMMINGS
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	227263
Policy instance	11
Insurance contract or identification number 227263 Number of Individuals Covered 1314 Insurance policy start date 2013-02-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $18,644 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $275,764 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,644 Insurance broker organization code? 3 Insurance broker name KATHERINE CUMMINGS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	906942
Policy instance	10
Insurance contract or identification number 906942 Number of Individuals Covered 115 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $101 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $1,013 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $101 Insurance broker organization code? 3 Insurance broker name KATHERINE CUMMINGS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	906943
Policy instance	9
Insurance contract or identification number 906943 Number of Individuals Covered 31 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $420 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided LIFESTYLE ADD & LIFESTYLE LIFE Welfare Benefit Premiums Paid to Carrier USD $2,801 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $420 Insurance broker organization code? 3 Insurance broker name KATHERINE CUMMINGS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	047318
Policy instance	8
Insurance contract or identification number 047318 Number of Individuals Covered 15 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $14 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $135 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 Insurance broker organization code? 3 Insurance broker name KATHERINE CUMMINGS
STERLING LIFE (National Association of Insurance Commissioners NAIC id number: 77399 )
Policy contract number	S 4802
Policy instance	7
Insurance contract or identification number S 4802 Number of Individuals Covered 48 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $16,606 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Welfare Benefit Premiums Paid to Carrier USD $152,256 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,769 Insurance broker organization code? 5 Insurance broker name BOLLINGER INC
MONUMENTAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 66281 )
Policy contract number	MZ0200635H0000A
Policy instance	6
Insurance contract or identification number MZ0200635H0000A Number of Individuals Covered 55 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $20,149 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $129,105 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,179 Insurance broker organization code? 5 Insurance broker name BOLLINGER INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010155398000
Policy instance	4
Insurance contract or identification number 000010155398000 Number of Individuals Covered 1251 Insurance policy start date 2013-02-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $11,981 Total amount of fees paid to insurance company USD $4,355 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $119,805 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,981 Amount paid for insurance broker fees 4355 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name BOLLINGER INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	906857
Policy instance	3
Insurance contract or identification number 906857 Number of Individuals Covered 244 Insurance policy start date 2013-01-01 Insurance policy end date 2013-02-01 Total amount of commissions paid to insurance broker USD $2,049 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided LIFESTYLE ADD & LIFESTYLE LIFE Welfare Benefit Premiums Paid to Carrier USD $12,795 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,049 Insurance broker organization code? 3 Insurance broker name KATHERINE CUMMINGS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	906866
Policy instance	2
Insurance contract or identification number 906866 Number of Individuals Covered 1115 Insurance policy start date 2013-01-01 Insurance policy end date 2013-02-01 Total amount of commissions paid to insurance broker USD $78 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $14,578 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 Insurance broker organization code? 3 Insurance broker name KATHERINE CUMMINGS
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	9361
Policy instance	1
Insurance contract or identification number 9361 Number of Individuals Covered 1111 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 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes 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	0008246461
Policy instance	13
Insurance contract or identification number 0008246461 Number of Individuals Covered 5 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 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,473 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0314808
Policy instance	5
Insurance contract or identification number 0314808 Number of Individuals Covered 2355 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 $94,630 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 55350 Additional information about fees paid to insurance broker MM EARLY PREMIER PRODUCER 1/1/2013 - 4/30/2013 RENEWAL BONUS Insurance broker organization code? 3 Insurance broker name BOLLINGER INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	906866
Policy instance	2
Insurance contract or identification number 906866 Number of Individuals Covered 1114 Insurance policy start date 2012-01-01 Insurance policy end date 2013-01-01 Total amount of commissions paid to insurance broker USD $357 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $167,549 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $357 Insurance broker organization code? 3 Insurance broker name CUMMINGS, KATHERINE
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	906857
Policy instance	3
Insurance contract or identification number 906857 Number of Individuals Covered 245 Insurance policy start date 2012-01-01 Insurance policy end date 2013-01-01 Total amount of commissions paid to insurance broker USD $1,608 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Other welfare benefits provided LIFESTYLE ADD & LIFESTLE LIFE Welfare Benefit Premiums Paid to Carrier USD $49,665 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,608 Insurance broker organization code? 3 Insurance broker name CUMMINGS, KATHERINE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010155398000
Policy instance	4
Insurance contract or identification number 000010155398000 Number of Individuals Covered 1189 Insurance policy start date 2012-02-01 Insurance policy end date 2013-01-31 Total amount of commissions paid to insurance broker USD $10,964 Total amount of fees paid to insurance company USD $0 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $109,637 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,964 Insurance broker organization code? 3 Insurance broker name BOLLINGER INC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	314808
Policy instance	5
Insurance contract or identification number 314808 Number of Individuals Covered 886 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 $60,200 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid as a credit? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 60200 Additional information about fees paid to insurance broker 2011 MEDICAL NEW SALES SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name BOLLINGER INC
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	9361
Policy instance	1
Insurance contract or identification number 9361 Number of Individuals Covered 1036 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 Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	9361
Policy instance	2
Insurance contract or identification number 9361 Number of Individuals Covered 835 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 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 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 $643,860 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008246461
Policy instance	8
Insurance contract or identification number 0008246461 Number of Individuals Covered 108 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACC, ISWL 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 $29,971 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	000000906942
Policy instance	5
Insurance contract or identification number 000000906942 Number of Individuals Covered 104 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No 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 $30,983 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	906857
Policy instance	6
Insurance contract or identification number 906857 Number of Individuals Covered 157 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LIFESTYLE ADD & LIFESTYLE LIFE 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 $46,842 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	000000906866
Policy instance	4
Insurance contract or identification number 000000906866 Number of Individuals Covered 851 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No 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 $202,953 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	906944
Policy instance	7
Insurance contract or identification number 906944 Number of Individuals Covered 105 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No 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 $47,930 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000064095705
Policy instance	3
Insurance contract or identification number 000064095705 Number of Individuals Covered 483 Insurance policy start date 2010-09-21 Insurance policy end date 2011-09-20 Total amount of commissions paid to insurance broker USD $236 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 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 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 $1,574 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	314808
Policy instance	1
Insurance contract or identification number 314808 Number of Individuals Covered 851 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 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 $7,072,192 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000064095705
Policy instance	4
Insurance contract or identification number 000064095705 Number of Individuals Covered 483 Insurance policy start date 2009-09-21 Insurance policy end date 2010-09-20 Total amount of commissions paid to insurance broker USD $236 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 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 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 $1,574 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $236 Insurance broker organization code? 3 Insurance broker name BOLLINGER INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	000000906866
Policy instance	5
Insurance contract or identification number 000000906866 Number of Individuals Covered 777 Insurance policy start date 2010-02-01 Insurance policy end date 2010-12-31 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No 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 $161,330 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )
Policy contract number	86506
Policy instance	1
Insurance contract or identification number 86506 Number of Individuals Covered 589 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $119,699 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 $4,614,007 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $119,699 Insurance broker organization code? 3 Insurance broker name ABSOLUTE RESOURCE SOLUTIONS
HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )
Policy contract number	86506
Policy instance	2
Insurance contract or identification number 86506 Number of Individuals Covered 589 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $27,067 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 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 $1,037,005 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $27,067 Insurance broker organization code? 3 Insurance broker name ABSOLUTE RESOURCE SOLUTIONS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	000000906942
Policy instance	6
Insurance contract or identification number 000000906942 Number of Individuals Covered 103 Insurance policy start date 2010-02-01 Insurance policy end date 2010-12-31 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No 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 $30,635 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )
Policy contract number	086506
Policy instance	3
Insurance contract or identification number 086506 Number of Individuals Covered 589 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 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 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 $481,773 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No

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