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UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 401k Plan overview

Plan NameUPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN
Plan identification number 501

UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

UPHAMS CORNER HEALTH COMMITTEE, INC. has sponsored the creation of one or more 401k plans.

Company Name:UPHAMS CORNER HEALTH COMMITTEE, INC.
Employer identification number (EIN):237211732
NAIC Classification:621498
NAIC Description:All Other Outpatient Care Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-02-01
5012021-02-01
5012020-02-01
5012019-02-01
5012018-02-01
5012017-02-01DANIEL DENNIS
5012016-02-01DANIEL DENNIS
5012015-02-01DANIEL DENNIS
5012014-02-01DANIEL DENNIS
5012013-02-01EDWARD GRIMES
5012012-02-01EDWARD GRIMES
5012011-02-01EDWARD GRIMES
5012010-02-01EDWARD F. GRIMES EDWARD F. GRIMES2012-07-31
5012009-02-01EDWARD F. GRIMES EDWARD F. GRIMES2012-07-31
5012009-02-01EDWARD F. GRIMES EDWARD F. GRIMES2010-10-15
5012008-02-01EDWARD F. GRIMES EDWARD F. GRIMES2012-07-31

Plan Statistics for UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN

401k plan membership statisitcs for UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN

Measure Date Value
2022: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-02-01406
Total number of active participants reported on line 7a of the Form 55002022-02-01403
Total of all active and inactive participants2022-02-01403
2021: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-02-01364
Total number of active participants reported on line 7a of the Form 55002021-02-01406
Total of all active and inactive participants2021-02-01406
2020: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-02-01336
Total number of active participants reported on line 7a of the Form 55002020-02-01364
Total of all active and inactive participants2020-02-01364
2019: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-02-01377
Total number of active participants reported on line 7a of the Form 55002019-02-01336
Total of all active and inactive participants2019-02-01336
2018: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-02-01249
Total number of active participants reported on line 7a of the Form 55002018-02-01374
Number of retired or separated participants receiving benefits2018-02-013
Number of other retired or separated participants entitled to future benefits2018-02-010
Total of all active and inactive participants2018-02-01377
2017: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-02-01186
Total number of active participants reported on line 7a of the Form 55002017-02-01249
Number of retired or separated participants receiving benefits2017-02-010
Number of other retired or separated participants entitled to future benefits2017-02-010
Total of all active and inactive participants2017-02-01249
2016: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-02-01228
Total number of active participants reported on line 7a of the Form 55002016-02-01185
Number of retired or separated participants receiving benefits2016-02-011
Number of other retired or separated participants entitled to future benefits2016-02-010
Total of all active and inactive participants2016-02-01186
2015: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-02-01271
Total number of active participants reported on line 7a of the Form 55002015-02-01225
Number of retired or separated participants receiving benefits2015-02-013
Number of other retired or separated participants entitled to future benefits2015-02-010
Total of all active and inactive participants2015-02-01228
2014: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-02-01167
Total number of active participants reported on line 7a of the Form 55002014-02-01271
Number of retired or separated participants receiving benefits2014-02-013
Number of other retired or separated participants entitled to future benefits2014-02-010
Total of all active and inactive participants2014-02-01274
2013: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-02-01204
Total number of active participants reported on line 7a of the Form 55002013-02-01167
Number of retired or separated participants receiving benefits2013-02-010
Number of other retired or separated participants entitled to future benefits2013-02-010
Total of all active and inactive participants2013-02-01167
2012: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-02-01213
Total number of active participants reported on line 7a of the Form 55002012-02-01204
Number of retired or separated participants receiving benefits2012-02-010
Number of other retired or separated participants entitled to future benefits2012-02-010
Total of all active and inactive participants2012-02-01204
2011: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-02-01284
Total number of active participants reported on line 7a of the Form 55002011-02-01213
Number of retired or separated participants receiving benefits2011-02-010
Number of other retired or separated participants entitled to future benefits2011-02-010
Total of all active and inactive participants2011-02-01213
2010: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-02-01277
Total number of active participants reported on line 7a of the Form 55002010-02-01284
Total of all active and inactive participants2010-02-01284
2009: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-02-01239
Total number of active participants reported on line 7a of the Form 55002009-02-01277
Number of retired or separated participants receiving benefits2009-02-010
Number of other retired or separated participants entitled to future benefits2009-02-010
Total of all active and inactive participants2009-02-01277
2008: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2008 401k membership
Total participants, beginning-of-year2008-02-01221
Total number of active participants reported on line 7a of the Form 55002008-02-01239
Number of retired or separated participants receiving benefits2008-02-010
Number of other retired or separated participants entitled to future benefits2008-02-010
Total of all active and inactive participants2008-02-01239

Form 5500 Responses for UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN

2022: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-02-01Type of plan entitySingle employer plan
2022-02-01This return/report is a short plan year return/report (less than 12 months)Yes
2022-02-01Plan funding arrangement – InsuranceYes
2022-02-01Plan funding arrangement – General assets of the sponsorYes
2022-02-01Plan benefit arrangement – InsuranceYes
2022-02-01Plan benefit arrangement – General assets of the sponsorYes
2021: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-02-01Type of plan entitySingle employer plan
2021-02-01Plan funding arrangement – InsuranceYes
2021-02-01Plan funding arrangement – General assets of the sponsorYes
2021-02-01Plan benefit arrangement – InsuranceYes
2021-02-01Plan benefit arrangement – General assets of the sponsorYes
2020: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-02-01Type of plan entitySingle employer plan
2020-02-01Plan funding arrangement – InsuranceYes
2020-02-01Plan funding arrangement – General assets of the sponsorYes
2020-02-01Plan benefit arrangement – InsuranceYes
2020-02-01Plan benefit arrangement – General assets of the sponsorYes
2019: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-02-01Type of plan entitySingle employer plan
2019-02-01Plan funding arrangement – InsuranceYes
2019-02-01Plan funding arrangement – General assets of the sponsorYes
2019-02-01Plan benefit arrangement – InsuranceYes
2019-02-01Plan benefit arrangement – General assets of the sponsorYes
2018: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-02-01Type of plan entitySingle employer plan
2018-02-01Plan funding arrangement – InsuranceYes
2018-02-01Plan funding arrangement – General assets of the sponsorYes
2018-02-01Plan benefit arrangement – InsuranceYes
2018-02-01Plan benefit arrangement – General assets of the sponsorYes
2017: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-02-01Type of plan entitySingle employer plan
2017-02-01Submission has been amendedNo
2017-02-01This submission is the final filingNo
2017-02-01This return/report is a short plan year return/report (less than 12 months)No
2017-02-01Plan is a collectively bargained planNo
2017-02-01Plan funding arrangement – InsuranceYes
2017-02-01Plan funding arrangement – General assets of the sponsorYes
2017-02-01Plan benefit arrangement – InsuranceYes
2017-02-01Plan benefit arrangement – General assets of the sponsorYes
2016: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-02-01Type of plan entitySingle employer plan
2016-02-01Submission has been amendedNo
2016-02-01This submission is the final filingNo
2016-02-01This return/report is a short plan year return/report (less than 12 months)No
2016-02-01Plan is a collectively bargained planNo
2016-02-01Plan funding arrangement – InsuranceYes
2016-02-01Plan funding arrangement – General assets of the sponsorYes
2016-02-01Plan benefit arrangement – InsuranceYes
2016-02-01Plan benefit arrangement – General assets of the sponsorYes
2015: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-02-01Type of plan entitySingle employer plan
2015-02-01Submission has been amendedNo
2015-02-01This submission is the final filingNo
2015-02-01This return/report is a short plan year return/report (less than 12 months)No
2015-02-01Plan is a collectively bargained planNo
2015-02-01Plan funding arrangement – InsuranceYes
2015-02-01Plan funding arrangement – General assets of the sponsorYes
2015-02-01Plan benefit arrangement – InsuranceYes
2015-02-01Plan benefit arrangement – General assets of the sponsorYes
2014: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-02-01Type of plan entitySingle employer plan
2014-02-01Submission has been amendedNo
2014-02-01This submission is the final filingNo
2014-02-01This return/report is a short plan year return/report (less than 12 months)No
2014-02-01Plan is a collectively bargained planNo
2014-02-01Plan funding arrangement – InsuranceYes
2014-02-01Plan benefit arrangement – InsuranceYes
2013: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-02-01Type of plan entitySingle employer plan
2013-02-01Submission has been amendedNo
2013-02-01This submission is the final filingNo
2013-02-01This return/report is a short plan year return/report (less than 12 months)No
2013-02-01Plan is a collectively bargained planNo
2013-02-01Plan funding arrangement – InsuranceYes
2013-02-01Plan benefit arrangement – InsuranceYes
2012: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-02-01Type of plan entitySingle employer plan
2012-02-01Submission has been amendedNo
2012-02-01This submission is the final filingNo
2012-02-01This return/report is a short plan year return/report (less than 12 months)No
2012-02-01Plan is a collectively bargained planNo
2012-02-01Plan funding arrangement – InsuranceYes
2012-02-01Plan benefit arrangement – InsuranceYes
2011: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-02-01Type of plan entitySingle employer plan
2011-02-01Submission has been amendedNo
2011-02-01This submission is the final filingNo
2011-02-01This return/report is a short plan year return/report (less than 12 months)No
2011-02-01Plan is a collectively bargained planNo
2011-02-01Plan funding arrangement – InsuranceYes
2011-02-01Plan benefit arrangement – InsuranceYes
2010: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2010 form 5500 responses
2010-02-01Type of plan entitySingle employer plan
2010-02-01Submission has been amendedYes
2010-02-01Plan funding arrangement – InsuranceYes
2010-02-01Plan benefit arrangement – InsuranceYes
2009: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-02-01Type of plan entitySingle employer plan
2009-02-01Submission has been amendedYes
2009-02-01This submission is the final filingNo
2009-02-01Plan funding arrangement – InsuranceYes
2009-02-01Plan benefit arrangement – InsuranceYes
2008: UPHAMS CORNER HEALTH COMMITTEE, INC. WELFARE BENEFITS PLAN 2008 form 5500 responses
2008-02-01Type of plan entitySingle employer plan
2008-02-01Submission has been amendedYes
2008-02-01This submission is the final filingNo
2008-02-01Plan funding arrangement – InsuranceYes
2008-02-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number015132
Policy instance 7
Insurance contract or identification number015132
Number of Individuals Covered403
Insurance policy start date2022-02-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $6,419
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $197,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,419
TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
Policy contract number78332000
Policy instance 1
Insurance contract or identification number78332000
Number of Individuals Covered375
Insurance policy start date2022-02-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $47,627
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,115,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,627
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10279041001
Policy instance 2
Insurance contract or identification number10279041001
Number of Individuals Covered251
Insurance policy start date2022-02-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,509
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,509
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number008590
Policy instance 3
Insurance contract or identification number008590
Number of Individuals Covered301
Insurance policy start date2022-02-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,592
Total amount of fees paid to insurance companyUSD $1,209
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,592
Amount paid for insurance broker fees1209
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number008590
Policy instance 4
Insurance contract or identification number008590
Number of Individuals Covered115
Insurance policy start date2022-02-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,230
Total amount of fees paid to insurance companyUSD $861
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,230
Amount paid for insurance broker fees861
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number008590
Policy instance 5
Insurance contract or identification number008590
Number of Individuals Covered302
Insurance policy start date2022-02-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,748
Total amount of fees paid to insurance companyUSD $3,324
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $47,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,748
Amount paid for insurance broker fees3324
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number008590
Policy instance 6
Insurance contract or identification number008590
Number of Individuals Covered286
Insurance policy start date2022-02-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $702
Total amount of fees paid to insurance companyUSD $492
Other welfare benefits providedMAPFML
Welfare Benefit Premiums Paid to CarrierUSD $7,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $702
Amount paid for insurance broker fees492
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number015132
Policy instance 1
Insurance contract or identification number015132
Number of Individuals Covered406
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $5,058
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $217,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,058
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number008590
Policy instance 2
Insurance contract or identification number008590
Number of Individuals Covered91
Total amount of commissions paid to insurance brokerUSD $1,011
Total amount of fees paid to insurance companyUSD $708
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,011
Amount paid for insurance broker fees708
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number008590
Policy instance 3
Insurance contract or identification number008590
Number of Individuals Covered318
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $5,798
Total amount of fees paid to insurance companyUSD $4,059
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $57,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,798
Amount paid for insurance broker fees4059
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number008590
Policy instance 4
Insurance contract or identification number008590
Number of Individuals Covered319
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $3,143
Total amount of fees paid to insurance companyUSD $1,466
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,943
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,143
Amount paid for insurance broker fees1466
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number008590
Policy instance 5
Insurance contract or identification number008590
Number of Individuals Covered289
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $7,985
Total amount of fees paid to insurance companyUSD $5,589
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $79,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,985
Amount paid for insurance broker fees5589
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10279041001
Policy instance 6
Insurance contract or identification number10279041001
Number of Individuals Covered228
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $1,564
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,564
TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
Policy contract number191227122046
Policy instance 7
Insurance contract or identification number191227122046
Number of Individuals Covered369
Total amount of commissions paid to insurance brokerUSD $42,371
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,371
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0012047550
Policy instance 8
Insurance contract or identification number0012047550
Number of Individuals Covered110
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $2,783
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $36,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,783
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number015132
Policy instance 7
Insurance contract or identification number015132
Number of Individuals Covered387
Insurance policy start date2020-03-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $7,447
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $189,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,447
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4955214
Policy instance 6
Insurance contract or identification number4955214
Number of Individuals Covered170
Insurance policy start date2020-02-01
Insurance policy end date2020-02-28
Total amount of commissions paid to insurance brokerUSD $540
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $540
TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
Policy contract number78332
Policy instance 5
Insurance contract or identification number78332
Number of Individuals Covered366
Insurance policy start date2020-03-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $37,737
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,737
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4955214
Policy instance 4
Insurance contract or identification number4955214
Number of Individuals Covered362
Insurance policy start date2020-02-01
Insurance policy end date2020-02-28
Total amount of commissions paid to insurance brokerUSD $3,519
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,519
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number102794041001
Policy instance 3
Insurance contract or identification number102794041001
Number of Individuals Covered186
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,333
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 number618818
Policy instance 2
Insurance contract or identification number618818
Number of Individuals Covered24
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $540
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $540
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number602484
Policy instance 1
Insurance contract or identification number602484
Number of Individuals Covered364
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $10,449
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $87,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,449
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number602484
Policy instance 1
Insurance contract or identification number602484
Number of Individuals Covered336
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $7,965
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $73,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,104
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number618818
Policy instance 2
Insurance contract or identification number618818
Number of Individuals Covered26
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $487
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $487
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0012047550
Policy instance 3
Insurance contract or identification number0012047550
Number of Individuals Covered137
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $7,906
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $45,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,906
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4955214
Policy instance 4
Insurance contract or identification number4955214
Number of Individuals Covered371
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $49,621
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,306,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,083
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4955214
Policy instance 5
Insurance contract or identification number4955214
Number of Individuals Covered334
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $7,478
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $186,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,940
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4955214
Policy instance 6
Insurance contract or identification number4955214
Number of Individuals Covered122
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $984
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $493
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4955214
Policy instance 1
Insurance contract or identification number4955214
Number of Individuals Covered197
Insurance policy start date2018-02-01
Insurance policy end date2019-01-31
Total amount of commissions paid to insurance brokerUSD $51,785
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,360,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,785
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number602484
Policy instance 2
Insurance contract or identification number602484
Number of Individuals Covered374
Insurance policy start date2018-02-01
Insurance policy end date2019-01-31
Total amount of commissions paid to insurance brokerUSD $11,646
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $78,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,646
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0012047550
Policy instance 3
Insurance contract or identification number0012047550
Number of Individuals Covered103
Insurance policy start date2018-08-01
Insurance policy end date2019-01-31
Total amount of commissions paid to insurance brokerUSD $4,462
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,462
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4955214
Policy instance 4
Insurance contract or identification number4955214
Number of Individuals Covered71
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $881
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 BrokerUSD $881
Insurance broker organization code?3
Insurance broker nameWEST RIDGE INSURANCE AGENCY, INC.
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4955214
Policy instance 3
Insurance contract or identification number4955214
Number of Individuals Covered192
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $41,418
Total amount of fees paid to insurance companyUSD $12,675
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 BrokerUSD $41,418
Amount paid for insurance broker fees12675
Additional information about fees paid to insurance brokerNON-EXPERIENCE RATED BONUS
Insurance broker organization code?3
Insurance broker nameWEST RIDGE INSURANCE AGENCY, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number602484
Policy instance 2
Insurance contract or identification number602484
Number of Individuals Covered249
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $7,411
Total amount of fees paid to insurance companyUSD $500
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $72,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,411
Amount paid for insurance broker fees500
Additional information about fees paid to insurance brokerNON-EXPERIENCE RATED BONUS
Insurance broker organization code?3
Insurance broker nameWEST RIDGE INSUANCE AGENCY, INC.
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4955214
Policy instance 1
Insurance contract or identification number4955214
Number of Individuals Covered183
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $7,239
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 BrokerUSD $7,239
Insurance broker organization code?3
Insurance broker nameWEST RIDGE INSURANCE AGENCY, INC.

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