THE PEP BOYS - MANNY, MOE AND JACK has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2015 : THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2015 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2015-01-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-01-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-01-31 | $7,217,919 |
| Total income from all sources (including contributions) | 2015-01-31 | $133,852 |
| Total loss/gain on sale of assets | 2015-01-31 | $0 |
| Total of all expenses incurred | 2015-01-31 | $133,852 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-01-31 | $125,939 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-01-31 | $133,847 |
| Value of total assets at end of year | 2015-01-31 | $0 |
| Value of total assets at beginning of year | 2015-01-31 | $7,217,919 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-01-31 | $7,913 |
| Total interest from all sources | 2015-01-31 | $5 |
| Total dividends received (eg from common stock, registered investment company shares) | 2015-01-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-01-31 | No |
| Was this plan covered by a fidelity bond | 2015-01-31 | Yes |
| Value of fidelity bond cover | 2015-01-31 | $10,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2015-01-31 | No |
| Contributions received from participants | 2015-01-31 | $133,847 |
| Administrative expenses (other) incurred | 2015-01-31 | $7,913 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-01-31 | No |
| Value of net income/loss | 2015-01-31 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2015-01-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-01-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-01-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-01-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-01-31 | No |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2015-01-31 | $5 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-01-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2015-01-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-01-31 | No |
| Employer contributions (assets) at end of year | 2015-01-31 | $0 |
| Employer contributions (assets) at beginning of year | 2015-01-31 | $7,217,919 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-01-31 | $125,939 |
| Liabilities. Value of benefit claims payable at end of year | 2015-01-31 | $0 |
| Liabilities. Value of benefit claims payable at beginning of year | 2015-01-31 | $7,217,919 |
| Did the plan have assets held for investment | 2015-01-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-01-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-01-31 | Yes |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-01-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2015-01-31 | Unqualified |
| Accountancy firm name | 2015-01-31 | BAKER TILLY VIRCHOW KRAUSE, LLP |
| Accountancy firm EIN | 2015-01-31 | 390859910 |
| 2014 : THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2014 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2014-02-01 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-02-01 | $7,217,919 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-02-01 | $7,212,814 |
| Total income from all sources (including contributions) | 2014-02-01 | $63,789,687 |
| Total loss/gain on sale of assets | 2014-02-01 | $0 |
| Total of all expenses incurred | 2014-02-01 | $63,789,687 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-02-01 | $63,519,197 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-02-01 | $63,789,680 |
| Value of total assets at end of year | 2014-02-01 | $7,217,919 |
| Value of total assets at beginning of year | 2014-02-01 | $7,212,814 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-02-01 | $270,490 |
| Total interest from all sources | 2014-02-01 | $7 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-02-01 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-02-01 | No |
| Was this plan covered by a fidelity bond | 2014-02-01 | Yes |
| Value of fidelity bond cover | 2014-02-01 | $10,000,000 |
| If this is an individual account plan, was there a blackout period | 2014-02-01 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2014-02-01 | No |
| Contributions received from participants | 2014-02-01 | $24,949,543 |
| Participant contributions at end of year | 2014-02-01 | $0 |
| Participant contributions at beginning of year | 2014-02-01 | $853,684 |
| Administrative expenses (other) incurred | 2014-02-01 | $270,490 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-02-01 | No |
| Value of net income/loss | 2014-02-01 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2014-02-01 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-02-01 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-02-01 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-02-01 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-02-01 | No |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2014-02-01 | $7 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-02-01 | $7,875,380 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-02-01 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2014-02-01 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-02-01 | No |
| Contributions received in cash from employer | 2014-02-01 | $38,840,137 |
| Employer contributions (assets) at end of year | 2014-02-01 | $7,217,919 |
| Employer contributions (assets) at beginning of year | 2014-02-01 | $6,359,130 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2014-02-01 | $55,643,817 |
| Liabilities. Value of benefit claims payable at end of year | 2014-02-01 | $7,217,919 |
| Liabilities. Value of benefit claims payable at beginning of year | 2014-02-01 | $7,212,814 |
| Did the plan have assets held for investment | 2014-02-01 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-02-01 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-02-01 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-02-01 | No |
| Opinion of an independent qualified public accountant for this plan | 2014-02-01 | Unqualified |
| Accountancy firm name | 2014-02-01 | BAKER TILLY VIRCHOW KRAUSE, LLP |
| Accountancy firm EIN | 2014-02-01 | 390859910 |
| 2013 : THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2013 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2013-02-02 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-02-02 | $7,212,814 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-02-02 | $6,680,889 |
| Total income from all sources (including contributions) | 2013-02-02 | $65,194,151 |
| Total loss/gain on sale of assets | 2013-02-02 | $0 |
| Total of all expenses incurred | 2013-02-02 | $65,194,151 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-02-02 | $61,331,844 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-02-02 | $65,192,589 |
| Value of total assets at end of year | 2013-02-02 | $7,212,814 |
| Value of total assets at beginning of year | 2013-02-02 | $6,680,889 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-02-02 | $3,862,307 |
| Total interest from all sources | 2013-02-02 | $1,562 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-02-02 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-02-02 | No |
| Was this plan covered by a fidelity bond | 2013-02-02 | Yes |
| Value of fidelity bond cover | 2013-02-02 | $10,000,000 |
| If this is an individual account plan, was there a blackout period | 2013-02-02 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-02-02 | No |
| Contributions received from participants | 2013-02-02 | $23,345,550 |
| Participant contributions at end of year | 2013-02-02 | $853,684 |
| Participant contributions at beginning of year | 2013-02-02 | $823,524 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2013-02-02 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2013-02-02 | $1 |
| Administrative expenses (other) incurred | 2013-02-02 | $3,862,307 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-02-02 | No |
| Value of net income/loss | 2013-02-02 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2013-02-02 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-02-02 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-02-02 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-02-02 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-02-02 | No |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2013-02-02 | $1,562 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-02-02 | $4,479,730 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-02-02 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2013-02-02 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-02-02 | No |
| Contributions received in cash from employer | 2013-02-02 | $41,847,039 |
| Employer contributions (assets) at end of year | 2013-02-02 | $6,359,130 |
| Employer contributions (assets) at beginning of year | 2013-02-02 | $5,857,364 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-02-02 | $56,852,114 |
| Liabilities. Value of benefit claims payable at end of year | 2013-02-02 | $7,212,814 |
| Liabilities. Value of benefit claims payable at beginning of year | 2013-02-02 | $6,680,889 |
| Did the plan have assets held for investment | 2013-02-02 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-02-02 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-02-02 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-02-02 | No |
| Opinion of an independent qualified public accountant for this plan | 2013-02-02 | Unqualified |
| Accountancy firm name | 2013-02-02 | PARENTEBEARD LLC |
| Accountancy firm EIN | 2013-02-02 | 232932984 |
| 2012 : THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2012 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2012-01-28 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-01-28 | $6,680,889 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-01-28 | $6,056,178 |
| Total income from all sources (including contributions) | 2012-01-28 | $62,383,674 |
| Total loss/gain on sale of assets | 2012-01-28 | $0 |
| Total of all expenses incurred | 2012-01-28 | $62,383,674 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-01-28 | $58,590,029 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-01-28 | $62,380,943 |
| Value of total assets at end of year | 2012-01-28 | $6,680,889 |
| Value of total assets at beginning of year | 2012-01-28 | $6,056,178 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-01-28 | $3,793,645 |
| Total interest from all sources | 2012-01-28 | $2,731 |
| Total dividends received (eg from common stock, registered investment company shares) | 2012-01-28 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-01-28 | No |
| Was this plan covered by a fidelity bond | 2012-01-28 | Yes |
| Value of fidelity bond cover | 2012-01-28 | $10,000,000 |
| If this is an individual account plan, was there a blackout period | 2012-01-28 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-01-28 | No |
| Contributions received from participants | 2012-01-28 | $21,602,513 |
| Participant contributions at end of year | 2012-01-28 | $823,524 |
| Participant contributions at beginning of year | 2012-01-28 | $737,084 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2012-01-28 | $1 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2012-01-28 | $3 |
| Administrative expenses (other) incurred | 2012-01-28 | $3,793,645 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-01-28 | No |
| Value of net income/loss | 2012-01-28 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2012-01-28 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-01-28 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-01-28 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-01-28 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-01-28 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2012-01-28 | $0 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2012-01-28 | $3 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2012-01-28 | $3 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2012-01-28 | $2,731 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-01-28 | $4,934,922 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-01-28 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2012-01-28 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-01-28 | No |
| Contributions received in cash from employer | 2012-01-28 | $40,778,430 |
| Employer contributions (assets) at end of year | 2012-01-28 | $5,857,364 |
| Employer contributions (assets) at beginning of year | 2012-01-28 | $5,319,088 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-01-28 | $53,655,107 |
| Liabilities. Value of benefit claims payable at end of year | 2012-01-28 | $6,680,889 |
| Liabilities. Value of benefit claims payable at beginning of year | 2012-01-28 | $6,056,178 |
| Did the plan have assets held for investment | 2012-01-28 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-01-28 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-01-28 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-01-28 | No |
| Opinion of an independent qualified public accountant for this plan | 2012-01-28 | Unqualified |
| Accountancy firm name | 2012-01-28 | PARENTEBEARD LLC |
| Accountancy firm EIN | 2012-01-28 | 232932984 |
| 2011 : THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2011 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2011-01-29 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-01-29 | $6,056,178 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-01-29 | $4,964,899 |
| Total income from all sources (including contributions) | 2011-01-29 | $57,295,271 |
| Total loss/gain on sale of assets | 2011-01-29 | $0 |
| Total of all expenses incurred | 2011-01-29 | $57,295,271 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-01-29 | $56,981,300 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-01-29 | $57,295,206 |
| Value of total assets at end of year | 2011-01-29 | $6,056,178 |
| Value of total assets at beginning of year | 2011-01-29 | $4,964,899 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-01-29 | $313,971 |
| Total interest from all sources | 2011-01-29 | $65 |
| Total dividends received (eg from common stock, registered investment company shares) | 2011-01-29 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-01-29 | No |
| Was this plan covered by a fidelity bond | 2011-01-29 | Yes |
| Value of fidelity bond cover | 2011-01-29 | $10,000,000 |
| If this is an individual account plan, was there a blackout period | 2011-01-29 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-01-29 | No |
| Contributions received from participants | 2011-01-29 | $19,649,220 |
| Participant contributions at end of year | 2011-01-29 | $737,084 |
| Participant contributions at beginning of year | 2011-01-29 | $681,097 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2011-01-29 | $3 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2011-01-29 | $23 |
| Administrative expenses (other) incurred | 2011-01-29 | $313,971 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-01-29 | No |
| Value of net income/loss | 2011-01-29 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2011-01-29 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-01-29 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-01-29 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-01-29 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-01-29 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2011-01-29 | $3 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2011-01-29 | $4 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2011-01-29 | $4 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2011-01-29 | $65 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-01-29 | $8,738,552 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-01-29 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2011-01-29 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-01-29 | No |
| Contributions received in cash from employer | 2011-01-29 | $37,645,986 |
| Employer contributions (assets) at end of year | 2011-01-29 | $5,319,088 |
| Employer contributions (assets) at beginning of year | 2011-01-29 | $4,283,775 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-01-29 | $48,242,748 |
| Liabilities. Value of benefit claims payable at end of year | 2011-01-29 | $6,056,178 |
| Liabilities. Value of benefit claims payable at beginning of year | 2011-01-29 | $4,964,899 |
| Did the plan have assets held for investment | 2011-01-29 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-01-29 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-01-29 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-01-29 | No |
| Opinion of an independent qualified public accountant for this plan | 2011-01-29 | Unqualified |
| Accountancy firm name | 2011-01-29 | PARENTEBEARD LLC |
| Accountancy firm EIN | 2011-01-29 | 232932984 |
| 2016: THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Single employer plan |
| 2016-02-01 | Submission has been amended | No |
| 2016-02-01 | This submission is the final filing | No |
| 2016-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-02-01 | Plan is a collectively bargained plan | No |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-02-01 | Type of plan entity | Single employer plan |
| 2015-02-01 | Submission has been amended | Yes |
| 2015-02-01 | This submission is the final filing | No |
| 2015-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-02-01 | Plan is a collectively bargained plan | No |
| 2015-02-01 | Plan funding arrangement – Insurance | Yes |
| 2015-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-02-02 | Type of plan entity | Single employer plan |
| 2014-02-02 | Submission has been amended | No |
| 2014-02-02 | This submission is the final filing | No |
| 2014-02-02 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2014-02-02 | Plan is a collectively bargained plan | No |
| 2014-02-02 | Plan funding arrangement – Insurance | Yes |
| 2014-02-02 | Plan funding arrangement – Trust | Yes |
| 2014-02-02 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-02-02 | Plan benefit arrangement – Insurance | Yes |
| 2014-02-02 | Plan benefit arrangement - Trust | Yes |
| 2014-02-02 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-01-29 | Type of plan entity | Single employer plan |
| 2012-01-29 | Submission has been amended | No |
| 2012-01-29 | This submission is the final filing | No |
| 2012-01-29 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-29 | Plan is a collectively bargained plan | No |
| 2012-01-29 | Plan funding arrangement – Insurance | Yes |
| 2012-01-29 | Plan funding arrangement – Trust | Yes |
| 2012-01-29 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-29 | Plan benefit arrangement - Trust | Yes |
| 2011: THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-01-30 | Type of plan entity | Single employer plan |
| 2011-01-30 | Submission has been amended | No |
| 2011-01-30 | This submission is the final filing | No |
| 2011-01-30 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2011-01-30 | Plan is a collectively bargained plan | No |
| 2011-01-30 | Plan funding arrangement – Insurance | Yes |
| 2011-01-30 | Plan funding arrangement – Trust | Yes |
| 2011-01-30 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-30 | Plan benefit arrangement - Trust | Yes |
| 2010: THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-01-31 | Type of plan entity | Single employer plan |
| 2010-01-31 | Submission has been amended | No |
| 2010-01-31 | This submission is the final filing | No |
| 2010-01-31 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2010-01-31 | Plan is a collectively bargained plan | No |
| 2010-01-31 | Plan funding arrangement – Insurance | Yes |
| 2010-01-31 | Plan funding arrangement – Trust | Yes |
| 2010-01-31 | Plan benefit arrangement – Insurance | Yes |
| 2010-01-31 | Plan benefit arrangement - Trust | Yes |
| 2009: THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-02-01 | Type of plan entity | Single employer plan |
| 2009-02-01 | Submission has been amended | No |
| 2009-02-01 | This submission is the final filing | No |
| 2009-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-02-01 | Plan is a collectively bargained plan | No |
| 2009-02-01 | Plan funding arrangement – Insurance | Yes |
| 2009-02-01 | Plan funding arrangement – Trust | Yes |
| 2009-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-02-01 | Plan benefit arrangement - Trust | Yes |
| 2008: THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2008 form 5500 responses |
|---|
| 2008-02-03 | Type of plan entity | Single employer plan |
| 2008-02-03 | Submission has been amended | Yes |
| 2008-02-03 | This submission is the final filing | No |
| 2008-02-03 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-02-03 | Plan is a collectively bargained plan | No |
| 2008-02-03 | Plan funding arrangement – Insurance | Yes |
| 2008-02-03 | Plan funding arrangement – Trust | Yes |
| 2008-02-03 | Plan benefit arrangement – Insurance | Yes |
| 2008-02-03 | Plan benefit arrangement - Trust | Yes |
| 2007: THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2007 form 5500 responses |
|---|
| 2007-02-04 | Type of plan entity | Single employer plan |
| 2007-02-04 | Submission has been amended | Yes |
| 2007-02-04 | This submission is the final filing | No |
| 2007-02-04 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-02-04 | Plan is a collectively bargained plan | No |
| 2007-02-04 | Plan funding arrangement – Insurance | Yes |
| 2007-02-04 | Plan funding arrangement – Trust | Yes |
| 2007-02-04 | Plan benefit arrangement – Insurance | Yes |
| 2007-02-04 | Plan benefit arrangement - Trust | Yes |
| 2006: THE PEP BOYS EMPLOYEE WELFARE BENEFITS PLAN 2006 form 5500 responses |
|---|
| 2006-01-28 | Type of plan entity | Single employer plan |
| 2006-01-28 | Submission has been amended | Yes |
| 2006-01-28 | This submission is the final filing | No |
| 2006-01-28 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2006-01-28 | Plan is a collectively bargained plan | No |
| 2006-01-28 | Plan funding arrangement – Insurance | Yes |
| 2006-01-28 | Plan funding arrangement – Trust | Yes |
| 2006-01-28 | Plan benefit arrangement – Insurance | Yes |
| 2006-01-28 | Plan benefit arrangement - Trust | Yes |
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 0000096026 |
| Policy instance | 5 |
| Insurance contract or identification number | 0000096026 | | Number of Individuals Covered | 2954 | | 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 $260,688 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 260688 | | Additional information about fees paid to insurance broker | FEE PAID | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| MAPFRE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77054 ) |
| Policy contract number | 357976 |
| Policy instance | 7 |
| Insurance contract or identification number | 357976 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $298 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $298 | | Insurance broker organization code? | 3 | | Insurance broker name | AON RISK SERVICES OF PR INC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755369 |
| Policy instance | 2 |
| Insurance contract or identification number | 755369 | | Number of Individuals Covered | 2294 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-30 | | Total amount of commissions paid to insurance broker | USD $10,165 | | Total amount of fees paid to insurance company | USD $34,504 | | 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 $1,921,589 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,165 | | Amount paid for insurance broker fees | 34504 | | Additional information about fees paid to insurance broker | SERVICE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 531097 |
| Policy instance | 3 |
| Insurance contract or identification number | 531097 | | Number of Individuals Covered | 2411 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-30 | | 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 | EMPLOYEE ASSISTANCE PROGRAM | | 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 $15,889 | | 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 | 800167 |
| Policy instance | 4 |
| Insurance contract or identification number | 800167 | | Number of Individuals Covered | 5784 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-30 | | Total amount of commissions paid to insurance broker | USD $202,898 | | Total amount of fees paid to insurance company | USD $4,756 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $31,245,870 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $154,068 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 4756 | | Additional information about fees paid to insurance broker | GI 2014 BONUS-RETENTION | | Insurance broker name | TRION GROUP A MARSH & MCLENNAN |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 50932-2 |
| Policy instance | 1 |
| Insurance contract or identification number | 50932-2 | | Number of Individuals Covered | 20477 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-30 | | Total amount of commissions paid to insurance broker | USD $108,235 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,067,515 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $98,281 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH USA INC. DBA TRION GROUP, |
|
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0005678 |
| Policy instance | 8 |
| Insurance contract or identification number | SP0005678 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-30 | | Total amount of commissions paid to insurance broker | USD $4,848 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $96,953 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,848 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE, INC |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | *SEE BELOW |
| Policy instance | 6 |
| Insurance contract or identification number | *SEE BELOW | | Number of Individuals Covered | 77 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-30 | | Total amount of commissions paid to insurance broker | USD $12,772 | | 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 $655,659 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,772 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 231696 |
| Policy instance | 11 |
| Insurance contract or identification number | 231696 | | Number of Individuals Covered | 881 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $66,940 | | 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 $3,038,730 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $66,940 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 604169 |
| Policy instance | 10 |
| Insurance contract or identification number | 604169 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $22,756 | | 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 $1,013,881 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,756 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| MCS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60030 ) |
| Policy contract number | 79-791253 |
| Policy instance | 9 |
| Insurance contract or identification number | 79-791253 | | Number of Individuals Covered | 400 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-30 | | Total amount of commissions paid to insurance broker | USD $80,786 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $80,786 | | Insurance broker organization code? | 3 | | Insurance broker name | AON RISK SOLUTIONS OF PR, INC. |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0755369 |
| Policy instance | 6 |
| Insurance contract or identification number | 0755369 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $128 | | Total amount of fees paid to insurance company | USD $4,020 | | 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 $227,784 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $128 | | Amount paid for insurance broker fees | 4020 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 50932-2 |
| Policy instance | 9 |
| Insurance contract or identification number | 50932-2 | | Number of Individuals Covered | 12251 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $138,904 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,199,316 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $138,904 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH USA INC |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3208268 |
| Policy instance | 8 |
| Insurance contract or identification number | 3208268 | | Number of Individuals Covered | 1853 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | PREPAID DENTAL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $391,099 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 0000096026 |
| Policy instance | 7 |
| Insurance contract or identification number | 0000096026 | | Number of Individuals Covered | 2754 | | 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 $142,294 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 142294 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURACE BROKERAGE LLC |
|
| UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 355282 |
| Policy instance | 10 |
| Insurance contract or identification number | 355282 | | Number of Individuals Covered | 220 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $24,383 | | 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 $1,219,162 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,383 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE L |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 604169 |
| Policy instance | 5 |
| Insurance contract or identification number | 604169 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $11,480 | | 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 $786,406 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,480 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 231696 |
| Policy instance | 4 |
| Insurance contract or identification number | 231696 | | Number of Individuals Covered | 665 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $33,369 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | 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 $2,228,311 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,369 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURACE BROKERAGE LLC |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0800167 |
| Policy instance | 3 |
| Insurance contract or identification number | 0800167 | | Number of Individuals Covered | 7281 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $175,453 | | Total amount of fees paid to insurance company | USD $19,556 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $32,501,242 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $175,453 | | Amount paid for insurance broker fees | 19556 | | Additional information about fees paid to insurance broker | GI 2014 BONUS - RETENTION GI 2013 BONUS - RETENTION | | Insurance broker organization code? | 3 | | Insurance broker name | TRION GROUP |
|
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 845063 |
| Policy instance | 2 |
| Insurance contract or identification number | 845063 | | Number of Individuals Covered | 2314 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 | EMPLOYEE ASSISTANCE PROGRAM | | 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 $13,566 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | SEE BELOW* |
| Policy instance | 1 |
| Insurance contract or identification number | SEE BELOW* | | Number of Individuals Covered | 116 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $17,334 | | 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 $866,681 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,334 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC DBA |
|
| MCS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60030 ) |
| Policy contract number | 79-750051 |
| Policy instance | 1 |
| Insurance contract or identification number | 79-750051 | | Number of Individuals Covered | 457 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $21,466 | | 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 | ORGAN TRANSPLANT, WITHOUT ORGAN TRANSPLANT | | 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 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 50932 |
| Policy instance | 2 |
| Insurance contract or identification number | 50932 | | Number of Individuals Covered | 12779 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $137,349 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,597,828 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3208268 |
| Policy instance | 3 |
| Insurance contract or identification number | 3208268 | | Number of Individuals Covered | 2004 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | PREPAID DENTAL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $406,044 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 845063A |
| Policy instance | 4 |
| Insurance contract or identification number | 845063A | | Number of Individuals Covered | 2300 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 | EAP | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,698 | | 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 | 0800167 |
| Policy instance | 5 |
| Insurance contract or identification number | 0800167 | | Number of Individuals Covered | 2058 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $178,465 | | Total amount of fees paid to insurance company | USD $28,159 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | 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 $1,018,524 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 3208268 |
| Policy instance | 6 |
| Insurance contract or identification number | 3208268 | | Number of Individuals Covered | 2348 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | 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 $454,693 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 62298-2 |
| Policy instance | 2 |
| Insurance contract or identification number | 62298-2 | | Number of Individuals Covered | 5829 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $75,548 | | 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 | INDIVIDUAL EXCESS RISK | | 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 $1,230,630 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $75,548 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
|
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 845063 |
| Policy instance | 3 |
| Insurance contract or identification number | 845063 | | Number of Individuals Covered | 2223 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 | EAP | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $11,631 | | 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 | 800167 |
| Policy instance | 4 |
| Insurance contract or identification number | 800167 | | Number of Individuals Covered | 2245 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $180,039 | | Total amount of fees paid to insurance company | USD $25,599 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | 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 $1,014,296 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $180,039 | | Amount paid for insurance broker fees | 25599 | | Additional information about fees paid to insurance broker | NEW BUSINESS | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY LLC |
|
| MCS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60030 ) |
| Policy contract number | 79-750051 |
| Policy instance | 5 |
| Insurance contract or identification number | 79-750051 | | Number of Individuals Covered | 458 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $20,249 | | 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 | WITHOUT ORGAN TRANSPLANT, ORGAN TRANSPLANT | | 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 | | Commission paid to Insurance Broker | USD $11,733 | | Insurance broker organization code? | 3 | | Insurance broker name | AXA ASSISTANCE USA, INC. |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 50932-1 |
| Policy instance | 1 |
| Insurance contract or identification number | 50932-1 | | Number of Individuals Covered | 12578 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $132,817 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,530,176 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $132,817 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH USA INC. DBA TRION GROUP, |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 62298-2 |
| Policy instance | 5 |
| Insurance contract or identification number | 62298-2 | | Number of Individuals Covered | 6106 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-28 | | Total amount of commissions paid to insurance broker | USD $60,346 | | 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 | INDIVIDUAL EXCESS RISK | | 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 $1,206,913 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 50932-1 |
| Policy instance | 4 |
| Insurance contract or identification number | 50932-1 | | Number of Individuals Covered | 12475 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-28 | | Total amount of commissions paid to insurance broker | USD $125,860 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $420,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| MCS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60030 ) |
| Policy contract number | 79-750051 |
| Policy instance | 3 |
| Insurance contract or identification number | 79-750051 | | Number of Individuals Covered | 429 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-28 | | Total amount of commissions paid to insurance broker | USD $8,808 | | 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 | WITHOUT ORGAN TRANSPLANT | | 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 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 800167 |
| Policy instance | 2 |
| Insurance contract or identification number | 800167 | | Number of Individuals Covered | 3937 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-28 | | Total amount of commissions paid to insurance broker | USD $221,858 | | Total amount of fees paid to insurance company | USD $67,892 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | 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 $1,060,915 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 845063 |
| Policy instance | 1 |
| Insurance contract or identification number | 845063 | | Number of Individuals Covered | 2057 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 | EAP | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,176 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 3208268 |
| Policy instance | 6 |
| Insurance contract or identification number | 3208268 | | Number of Individuals Covered | 2585 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | 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 $469,213 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 62298-2 |
| Policy instance | 4 |
| Insurance contract or identification number | 62298-2 | | Number of Individuals Covered | 6059 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $54,353 | | 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 | INDIVIDUAL EXCESS RISK | | 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 $1,087,066 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 3208268 |
| Policy instance | 2 |
| Insurance contract or identification number | 3208268 | | Number of Individuals Covered | 2770 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | 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 $485,561 | | 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 | 800167 |
| Policy instance | 1 |
| Insurance contract or identification number | 800167 | | Number of Individuals Covered | 16678 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $77,770 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,813,340 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MCS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60030 ) |
| Policy contract number | 79-750051 |
| Policy instance | 3 |
| Insurance contract or identification number | 79-750051 | | Number of Individuals Covered | 433 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $39,643 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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