401k Plan data: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN plan

PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 401k Plan overview

Plan Name	PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN
Plan identification number	501

PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

SPARTRONICS WILLIAMSPORT, INC. has sponsored the creation of one or more 401k plans.

Company Name: SPARTRONICS WILLIAMSPORT, INC.

Employer identification number (EIN): 232736400

NAIC Classification: 339900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-01-01 KEVIN STIADLE 2022-10-17
501 2021-01-01 DEBBIE CARDON 2024-02-21
501 2020-01-01 KEVIN STIADLE 2021-10-06
501 2019-01-01 CHRISTOPHER R. SULLIVAN 2020-07-23
501 2018-01-01 CHRISTOPHER R. SULLIVAN 2019-10-04
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 CHRISTOPHER SULLIVAN
501 2011-01-01 CHRISTOPHER B. SULLIVAN
501 2009-01-01 CHRISTOPHER B. SULLIVAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2021-01-01	KEVIN STIADLE	2022-10-17
501	2021-01-01	DEBBIE CARDON	2024-02-21
501	2020-01-01	KEVIN STIADLE	2021-10-06
501	2019-01-01	CHRISTOPHER R. SULLIVAN	2020-07-23
501	2018-01-01	CHRISTOPHER R. SULLIVAN	2019-10-04
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	CHRISTOPHER SULLIVAN
501	2011-01-01	CHRISTOPHER B. SULLIVAN
501	2009-01-01	CHRISTOPHER B. SULLIVAN

Plan Statistics for PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN

401k plan membership statisitcs for PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN

Measure Date Value
2021: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 329
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 311
Number of retired or separated participants receiving benefits 2021-01-01 8
Total of all active and inactive participants 2021-01-01 319
Total participants 2021-01-01 319
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
2020: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 405
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 321
Number of retired or separated participants receiving benefits 2020-01-01 8
Total of all active and inactive participants 2020-01-01 329
Total participants 2020-01-01 329
2019: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 413
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 400
Number of retired or separated participants receiving benefits 2019-01-01 5
Total of all active and inactive participants 2019-01-01 405
Total participants 2019-01-01 405
2018: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 554
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 408
Number of retired or separated participants receiving benefits 2018-01-01 5
Total of all active and inactive participants 2018-01-01 413
Total participants 2018-01-01 413
2017: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 642
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 336
Number of retired or separated participants receiving benefits 2017-01-01 11
Total of all active and inactive participants 2017-01-01 347
Total participants 2017-01-01 347
2016: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 425
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 429
Number of retired or separated participants receiving benefits 2016-01-01 6
Total of all active and inactive participants 2016-01-01 435
Total participants 2016-01-01 435
2015: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 407
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 418
Number of retired or separated participants receiving benefits 2015-01-01 7
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 425
Total participants 2015-01-01 425
2014: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 408
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 402
Number of retired or separated participants receiving benefits 2014-01-01 5
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 407
2013: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 472
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 406
Number of retired or separated participants receiving benefits 2013-01-01 2
Total of all active and inactive participants 2013-01-01 408
2012: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 470
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 466
Number of retired or separated participants receiving benefits 2012-01-01 6
Total of all active and inactive participants 2012-01-01 472
2011: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 427
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 465
Number of retired or separated participants receiving benefits 2011-01-01 5
Total of all active and inactive participants 2011-01-01 470
2009: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 455
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 310
Number of retired or separated participants receiving benefits 2009-01-01 20
Total of all active and inactive participants 2009-01-01 330

Measure	Date	Value
2021: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	329
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	311
Number of retired or separated participants receiving benefits	2021-01-01	8
Total of all active and inactive participants	2021-01-01	319
Total participants	2021-01-01	319
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
2020: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	405
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	321
Number of retired or separated participants receiving benefits	2020-01-01	8
Total of all active and inactive participants	2020-01-01	329
Total participants	2020-01-01	329
2019: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	413
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	400
Number of retired or separated participants receiving benefits	2019-01-01	5
Total of all active and inactive participants	2019-01-01	405
Total participants	2019-01-01	405
2018: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	554
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	408
Number of retired or separated participants receiving benefits	2018-01-01	5
Total of all active and inactive participants	2018-01-01	413
Total participants	2018-01-01	413
2017: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	642
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	336
Number of retired or separated participants receiving benefits	2017-01-01	11
Total of all active and inactive participants	2017-01-01	347
Total participants	2017-01-01	347
2016: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	425
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	429
Number of retired or separated participants receiving benefits	2016-01-01	6
Total of all active and inactive participants	2016-01-01	435
Total participants	2016-01-01	435
2015: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	407
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	418
Number of retired or separated participants receiving benefits	2015-01-01	7
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	425
Total participants	2015-01-01	425
2014: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	408
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	402
Number of retired or separated participants receiving benefits	2014-01-01	5
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	407
2013: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	472
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	406
Number of retired or separated participants receiving benefits	2013-01-01	2
Total of all active and inactive participants	2013-01-01	408
2012: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	470
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	466
Number of retired or separated participants receiving benefits	2012-01-01	6
Total of all active and inactive participants	2012-01-01	472
2011: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	427
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	465
Number of retired or separated participants receiving benefits	2011-01-01	5
Total of all active and inactive participants	2011-01-01	470
2009: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	455
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	310
Number of retired or separated participants receiving benefits	2009-01-01	20
Total of all active and inactive participants	2009-01-01	330

Form 5500 Responses for PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN

2021: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	Yes
2021-01-01	This submission is the final filing	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: PRIMUS TECHNOLOGIES FLEXIBLE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0564161

Policy instance

Insurance contract or identification number	R0564161
Number of Individuals Covered	21
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $644
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $5,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $494
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

254457-000

Policy instance

Insurance contract or identification number	254457-000
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	138
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,717
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $29,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,717
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	57
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,539
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,539
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )

Policy contract number

10117947

Policy instance

Insurance contract or identification number	10117947
Number of Individuals Covered	37
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $207,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30063506

Policy instance

Insurance contract or identification number	30063506
Number of Individuals Covered	253
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )

Policy contract number

9434-MNL

Policy instance

Insurance contract or identification number	9434-MNL
Number of Individuals Covered	323
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,476
Total amount of fees paid to insurance company	USD $5,903
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $270,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,265
Insurance broker organization code?	3
Amount paid for insurance broker fees	5903
Additional information about fees paid to insurance broker	TPA FEES

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

10117947

Policy instance

Insurance contract or identification number	10117947
Number of Individuals Covered	386
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,398,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	151
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,657
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $34,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,657
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

254457-000

Policy instance

Insurance contract or identification number	254457-000
Number of Individuals Covered	601
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	68
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,075
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,075
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0564161

Policy instance

Insurance contract or identification number	R0564161
Number of Individuals Covered	24
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $877
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $6,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $877
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )

Policy contract number

9434-MNL

Policy instance

Insurance contract or identification number	9434-MNL
Number of Individuals Covered	388
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $9,966
Total amount of fees paid to insurance company	USD $5,597
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,966
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3
Amount paid for insurance broker fees	5597

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30063506

Policy instance

Insurance contract or identification number	30063506
Number of Individuals Covered	280
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

10117947-1001

Policy instance

Insurance contract or identification number	10117947-1001
Number of Individuals Covered	456
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,642,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )

Policy contract number

10117947-1000

Policy instance

Insurance contract or identification number	10117947-1000
Number of Individuals Covered	35
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $248,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )

Policy contract number

9434-MNL

Policy instance

Insurance contract or identification number	9434-MNL
Number of Individuals Covered	554
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $10,010
Total amount of fees paid to insurance company	USD $5,468
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $285,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,010
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3
Amount paid for insurance broker fees	5468

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	70
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,515
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,515
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0564161

Policy instance

Insurance contract or identification number	R0564161
Number of Individuals Covered	26
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $1,284
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $6,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,284
Insurance broker organization code?	3

GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )

Policy contract number

117947

Policy instance

Insurance contract or identification number	117947
Number of Individuals Covered	35
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $275,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	164
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,893
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $36,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,893
Insurance broker organization code?	3

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

10117947-1001

Policy instance

Insurance contract or identification number	10117947-1001
Number of Individuals Covered	468
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,796,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

254457-000

Policy instance

Insurance contract or identification number	254457-000
Number of Individuals Covered	663
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30063506

Policy instance

Insurance contract or identification number	30063506
Number of Individuals Covered	287
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	58
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,570
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,570
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

254457-000

Policy instance

Insurance contract or identification number	254457-000
Number of Individuals Covered	594
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	152
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,334
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $32,545
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,334
Insurance broker organization code?	3

GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )

Policy contract number

117947

Policy instance

Insurance contract or identification number	117947
Number of Individuals Covered	47
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $236,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30063506

Policy instance

Insurance contract or identification number	30063506
Number of Individuals Covered	284
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $901
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $901
Insurance broker organization code?	3

MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )

Policy contract number

9434-MNL

Policy instance

Insurance contract or identification number	9434-MNL
Number of Individuals Covered	542
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,645
Total amount of fees paid to insurance company	USD $4,879
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $246,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,645
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

1179470004

Policy instance

Insurance contract or identification number	1179470004
Number of Individuals Covered	473
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,407,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0564161

Policy instance

Insurance contract or identification number	R0564161
Number of Individuals Covered	28
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $1,043
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $6,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,043
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30063506

Policy instance

Insurance contract or identification number	30063506
Number of Individuals Covered	254
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker name

MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )

Policy contract number

9434-MNL

Policy instance

Insurance contract or identification number	9434-MNL
Number of Individuals Covered	543
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $10,419
Total amount of fees paid to insurance company	USD $11,432
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $297,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,419
Amount paid for insurance broker fees	5716
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3
Insurance broker name	NORTH AMERICAN BENEFITS COMPANY

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

1179470004

Policy instance

Insurance contract or identification number	1179470004
Number of Individuals Covered	517
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,201,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )

Policy contract number

117947

Policy instance

Insurance contract or identification number	117947
Number of Individuals Covered	66
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $418,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0564161

Policy instance

Insurance contract or identification number	R0564161
Number of Individuals Covered	30
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $1,630
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $7,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,630
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	39
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,774
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,774
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

254457-000

Policy instance

Insurance contract or identification number	254457-000
Number of Individuals Covered	724
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	157
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,456
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $36,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,456
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	187
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,998
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $45,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,998
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

BLUE CROSS OF NORTHEASTERN PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 60147 )

Policy contract number

500720

Policy instance

Insurance contract or identification number	500720
Number of Individuals Covered	629
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,472,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	24
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $838
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $838
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

254457-000

Policy instance

Insurance contract or identification number	254457-000
Number of Individuals Covered	688
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

000000213517

Policy instance

Insurance contract or identification number	000000213517
Number of Individuals Covered	418
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $27,159
Total amount of fees paid to insurance company	USD $12,075
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $241,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,159
Amount paid for insurance broker fees	12075
Insurance broker name	EMERSON REID LLC

BLUE CROSS OF NORTHEASTERN PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 60147 )

Policy contract number

204155

Policy instance

Insurance contract or identification number	204155
Number of Individuals Covered	25
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS OF NORTHEASTERN PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 60147 )

Policy contract number

204155500720

Policy instance

Insurance contract or identification number	204155500720
Number of Individuals Covered	636
Insurance policy start date	2014-12-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	204
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,391
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $39,363
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,391
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	20
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $425
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,363
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $425
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

254457-000

Policy instance

Insurance contract or identification number	254457-000
Number of Individuals Covered	705
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

000000213517

Policy instance

Insurance contract or identification number	000000213517
Number of Individuals Covered	402
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $27,271
Total amount of fees paid to insurance company	USD $12,063
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $241,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,271
Insurance broker organization code?	3
Amount paid for insurance broker fees	12063
Insurance broker name	EMERSON REID LLC

BLUE CROSS OF NORTHEASTERN PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 60147 )

Policy contract number

204155500720

Policy instance

Insurance contract or identification number	204155500720
Number of Individuals Covered	680
Insurance policy start date	2013-12-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

000000213517

Policy instance

Insurance contract or identification number	000000213517
Number of Individuals Covered	415
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $26,467
Total amount of fees paid to insurance company	USD $11,715
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $234,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,467
Insurance broker organization code?	3
Amount paid for insurance broker fees	11715
Insurance broker name	EMERSON REID LLC

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

254457-000

Policy instance

Insurance contract or identification number	254457-000
Number of Individuals Covered	751
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

1806190000

Policy instance

Insurance contract or identification number	1806190000
Number of Individuals Covered	0
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,041,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	18
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $838
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,502
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $838
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

1806190000

Policy instance

Insurance contract or identification number	1806190000
Number of Individuals Covered	0
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

STD

Policy instance

Insurance contract or identification number	STD
Number of Individuals Covered	0
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $10
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $78
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
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	202
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,047
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $41,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,047
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	206
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,396
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $40,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,396
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	8
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $582
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $582
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

1806190000

Policy instance

Insurance contract or identification number	1806190000
Number of Individuals Covered	4
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

6421-KCL

Policy instance

Insurance contract or identification number	6421-KCL
Number of Individuals Covered	586
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,154
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,154
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

STD

Policy instance

Insurance contract or identification number	STD
Number of Individuals Covered	158
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,477
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,477
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

254457-000

Policy instance

Insurance contract or identification number	254457-000
Number of Individuals Covered	836
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )

Policy contract number

6421-4EL

Policy instance

Insurance contract or identification number	6421-4EL
Number of Individuals Covered	466
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,520
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $62,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,520
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

1806190000

Policy instance

Insurance contract or identification number	1806190000
Number of Individuals Covered	686
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,583,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

1806190000

Policy instance

Insurance contract or identification number	1806190000
Number of Individuals Covered	4
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	15
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $614
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

6421-KCL

Policy instance

Insurance contract or identification number	6421-KCL
Number of Individuals Covered	591
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,689
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

128415

Policy instance

Insurance contract or identification number	128415
Number of Individuals Covered	0
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $53
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

STD

Policy instance

Insurance contract or identification number	STD
Number of Individuals Covered	169
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,469
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

254457-000

Policy instance

Insurance contract or identification number	254457-000
Number of Individuals Covered	847
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )

Policy contract number

6421-BCS

Policy instance

Insurance contract or identification number	6421-BCS
Number of Individuals Covered	501
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,167
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $63,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	216
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,949
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $36,888
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

1806190000

Policy instance

Insurance contract or identification number	1806190000
Number of Individuals Covered	762
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,195,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

035381 052784

Policy instance

Insurance contract or identification number	035381 052784
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS OF NORTHEASTERN PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54747 )

Policy contract number

035381 052784

Policy instance

Insurance contract or identification number	035381 052784
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

STD

Policy instance

Insurance contract or identification number	STD
Number of Individuals Covered	137
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,692
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,692
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

254457-000

Policy instance

Insurance contract or identification number	254457-000
Number of Individuals Covered	767
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )

Policy contract number

LO 6421

Policy instance

Insurance contract or identification number	LO 6421
Number of Individuals Covered	410
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,895
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,895
Insurance broker name	ROCHE FINANCIAL INC

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	108
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,504
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $30,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,504
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

128415

Policy instance

Insurance contract or identification number	128415
Number of Individuals Covered	473
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,637
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,637
Insurance broker organization code?	3
Insurance broker name	ROCHE FINANCIAL INC

BLUE CROSS OF NORTHEASTERN PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 60147 )

Policy contract number

035381 052784

Policy instance

Insurance contract or identification number	035381 052784
Number of Individuals Covered	653
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SPARTRONICS WILLIAMSPORT, INC.
Employer identification number (EIN):	232736400
NAIC Classification:	339900