401k Plan data: HEALTH AND WELFARE PLAN plan

HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	HEALTH AND WELFARE PLAN
Plan identification number	502

HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

OBSERVER PUBLISHING COMPANY has sponsored the creation of one or more 401k plans.

Company Name: OBSERVER PUBLISHING COMPANY

Employer identification number (EIN): 250699690

NAIC Classification: 511110
NAIC Description: Newspaper Publishers

Additional information about OBSERVER PUBLISHING COMPANY

Jurisdiction of Incorporation: Georgia Department of States Corporations Division

Incorporation Date:

Company Identification Number: 451187

More information about OBSERVER PUBLISHING COMPANY

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2018-01-01 DAVID F. LYLE 2019-08-20
502 2017-01-01
502 2016-01-01
502 2015-01-01
502 2014-01-01
502 2013-01-01
502 2012-01-01 DAVID F. LYLE, CFO
502 2011-01-01 DAVID F. LYLE, CFO
502 2010-01-01 DAVID F. LYLE, CFO
502 2009-01-01 DAVID F. LYLE, CFO

Plan Statistics for HEALTH AND WELFARE PLAN

401k plan membership statisitcs for HEALTH AND WELFARE PLAN

Measure Date Value
2018: HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 185
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 0
Number of retired or separated participants receiving benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 0
2017: HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 186
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 181
Number of retired or separated participants receiving benefits 2017-01-01 4
Total of all active and inactive participants 2017-01-01 185
2016: HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 194
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 182
Number of retired or separated participants receiving benefits 2016-01-01 4
Total of all active and inactive participants 2016-01-01 186
2015: HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 192
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 189
Number of retired or separated participants receiving benefits 2015-01-01 5
Total of all active and inactive participants 2015-01-01 194
2014: HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 190
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 188
Number of retired or separated participants receiving benefits 2014-01-01 4
Total of all active and inactive participants 2014-01-01 192
2013: HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 184
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 166
Number of retired or separated participants receiving benefits 2013-01-01 24
Total of all active and inactive participants 2013-01-01 190
2012: HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 184
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 178
Number of retired or separated participants receiving benefits 2012-01-01 6
Total of all active and inactive participants 2012-01-01 184
2011: HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 189
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 177
Number of retired or separated participants receiving benefits 2011-01-01 7
Total of all active and inactive participants 2011-01-01 184
2010: HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 188
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 181
Number of retired or separated participants receiving benefits 2010-01-01 8
Total of all active and inactive participants 2010-01-01 189
2009: HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 286
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 128
Number of retired or separated participants receiving benefits 2009-01-01 60
Total of all active and inactive participants 2009-01-01 188
Total participants 2009-01-01 188

Measure	Date	Value
2018: HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	185
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	0
Number of retired or separated participants receiving benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	0
2017: HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	186
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	181
Number of retired or separated participants receiving benefits	2017-01-01	4
Total of all active and inactive participants	2017-01-01	185
2016: HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	194
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	182
Number of retired or separated participants receiving benefits	2016-01-01	4
Total of all active and inactive participants	2016-01-01	186
2015: HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	192
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	189
Number of retired or separated participants receiving benefits	2015-01-01	5
Total of all active and inactive participants	2015-01-01	194
2014: HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	190
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	188
Number of retired or separated participants receiving benefits	2014-01-01	4
Total of all active and inactive participants	2014-01-01	192
2013: HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	184
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	166
Number of retired or separated participants receiving benefits	2013-01-01	24
Total of all active and inactive participants	2013-01-01	190
2012: HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	184
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	178
Number of retired or separated participants receiving benefits	2012-01-01	6
Total of all active and inactive participants	2012-01-01	184
2011: HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	189
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	177
Number of retired or separated participants receiving benefits	2011-01-01	7
Total of all active and inactive participants	2011-01-01	184
2010: HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	188
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	181
Number of retired or separated participants receiving benefits	2010-01-01	8
Total of all active and inactive participants	2010-01-01	189
2009: HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	286
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	128
Number of retired or separated participants receiving benefits	2009-01-01	60
Total of all active and inactive participants	2009-01-01	188
Total participants	2009-01-01	188

Form 5500 Responses for HEALTH AND WELFARE PLAN

2018: HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	This submission is the final filing	Yes
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: HEALTH AND WELFARE 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: HEALTH AND WELFARE 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: HEALTH AND WELFARE 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: HEALTH AND WELFARE 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: HEALTH AND WELFARE 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: HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	Yes
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: HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	Yes
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
2010: HEALTH AND WELFARE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: HEALTH AND WELFARE 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

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090800

Policy instance

Insurance contract or identification number	019090800
Number of Individuals Covered	74
Insurance policy start date	2018-08-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $1,926
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,926
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0105493

Policy instance

Insurance contract or identification number	0105493
Number of Individuals Covered	182
Insurance policy start date	2018-01-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $64,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00479690

Policy instance

Insurance contract or identification number	00479690
Number of Individuals Covered	92
Insurance policy start date	2018-01-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $2,500
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,451
Insurance broker organization code?	3

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090904

Policy instance

Insurance contract or identification number	019090904
Number of Individuals Covered	0
Insurance policy start date	2018-01-01
Insurance policy end date	2018-07-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090801

Policy instance

Insurance contract or identification number	019090801
Number of Individuals Covered	50
Insurance policy start date	2018-08-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $1,478
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,381
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,478
Insurance broker organization code?	3

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090903

Policy instance

Insurance contract or identification number	019090903
Number of Individuals Covered	0
Insurance policy start date	2018-08-01
Insurance policy end date	2018-09-30
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090904

Policy instance

Insurance contract or identification number	019090904
Insurance policy start date	2018-08-01
Insurance policy end date	2018-09-30
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090800

Policy instance

Insurance contract or identification number	019090800
Number of Individuals Covered	76
Insurance policy start date	2018-01-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $6,671
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $221,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,671
Insurance broker organization code?	3

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090801

Policy instance

Insurance contract or identification number	019090801
Number of Individuals Covered	53
Insurance policy start date	2018-01-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $5,636
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $185,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,636
Insurance broker organization code?	3

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090903

Policy instance

Insurance contract or identification number	019090903
Number of Individuals Covered	0
Insurance policy start date	2018-01-01
Insurance policy end date	2018-07-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090800

Policy instance

Insurance contract or identification number	019090800
Number of Individuals Covered	81
Insurance policy start date	2017-08-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,059
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $202,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,059
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

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

Policy contract number

00479690

Policy instance

Insurance contract or identification number	00479690
Number of Individuals Covered	99
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,684
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,636
Insurance broker organization code?	3
Insurance broker name	LIFETIME FINANCIAL GROWTH, LLC

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0105493

Policy instance

Insurance contract or identification number	0105493
Number of Individuals Covered	181
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
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $80,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090801

Policy instance

Insurance contract or identification number	019090801
Number of Individuals Covered	58
Insurance policy start date	2017-08-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,255
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $171,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,255
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090903

Policy instance

Insurance contract or identification number	019090903
Number of Individuals Covered	0
Insurance policy start date	2017-08-01
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090904

Policy instance

Insurance contract or identification number	019090904
Number of Individuals Covered	0
Insurance policy start date	2017-08-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $-10
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $-349
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	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090800

Policy instance

Insurance contract or identification number	019090800
Number of Individuals Covered	82
Insurance policy start date	2017-01-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $7,164
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $203,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,164
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090801

Policy instance

Insurance contract or identification number	019090801
Number of Individuals Covered	52
Insurance policy start date	2017-01-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $5,517
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $154,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,517
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090903

Policy instance

Insurance contract or identification number	019090903
Number of Individuals Covered	0
Insurance policy start date	2017-01-01
Insurance policy end date	2017-07-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090904

Policy instance

Insurance contract or identification number	019090904
Number of Individuals Covered	3
Insurance policy start date	2017-01-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $555
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $555
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090302

Policy instance

Insurance contract or identification number	019090302
Number of Individuals Covered	45
Insurance policy start date	2015-01-01
Insurance policy end date	2015-07-31
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 $134,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0105493

Policy instance

Insurance contract or identification number	0105493
Number of Individuals Covered	189
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
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $70,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00479690

Policy instance

Insurance contract or identification number	00479690
Number of Individuals Covered	114
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,620
Total amount of fees paid to insurance company	USD $3,441
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,620
Amount paid for insurance broker fees	3441
Insurance broker organization code?	3
Insurance broker name	PATRICIA M. CUMMINGS

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090900

Policy instance

Insurance contract or identification number	019090900
Number of Individuals Covered	0
Insurance policy start date	2015-01-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $63
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090800

Policy instance

Insurance contract or identification number	019090800
Number of Individuals Covered	98
Insurance policy start date	2015-08-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,972
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $238,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,972
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090902

Policy instance

Insurance contract or identification number	019090902
Number of Individuals Covered	0
Insurance policy start date	2015-01-01
Insurance policy end date	2015-07-31
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 $459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090300

Policy instance

Insurance contract or identification number	019090300
Number of Individuals Covered	122
Insurance policy start date	2015-01-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $9,198
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $258,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,198
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090801

Policy instance

Insurance contract or identification number	019090801
Number of Individuals Covered	75
Insurance policy start date	2015-08-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,993
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $241,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,993
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090903

Policy instance

Insurance contract or identification number	019090903
Number of Individuals Covered	1
Insurance policy start date	2015-08-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $27
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,326
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
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090904

Policy instance

Insurance contract or identification number	019090904
Number of Individuals Covered	0
Insurance policy start date	2015-08-01
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090302

Policy instance

Insurance contract or identification number	019090302
Number of Individuals Covered	48
Insurance policy start date	2014-08-01
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
Welfare Benefit Premiums Paid to Carrier	USD $151,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090902

Policy instance

Insurance contract or identification number	019090902
Number of Individuals Covered	1
Insurance policy start date	2014-08-01
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
Welfare Benefit Premiums Paid to Carrier	USD $2,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0105493

Policy instance

Insurance contract or identification number	0105493
Number of Individuals Covered	188
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
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $66,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00479690

Policy instance

Insurance contract or identification number	00479690
Number of Individuals Covered	116
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,693
Total amount of fees paid to insurance company	USD $3,615
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,693
Amount paid for insurance broker fees	3615
Insurance broker organization code?	3
Insurance broker name	PATRICIA M. CUMMINGS

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090300

Policy instance

Insurance contract or identification number	019090300
Number of Individuals Covered	121
Insurance policy start date	2014-08-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,384
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 $258,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,384
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090900

Policy instance

Insurance contract or identification number	019090900
Number of Individuals Covered	3
Insurance policy start date	2014-01-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $409
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 $9,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $409
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090900

Policy instance

Insurance contract or identification number	019090900
Number of Individuals Covered	2
Insurance policy start date	2014-08-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $402
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 $4,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $402
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090300

Policy instance

Insurance contract or identification number	019090300
Number of Individuals Covered	97
Insurance policy start date	2014-01-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $6,238
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 $177,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,238
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090300

Policy instance

Insurance contract or identification number	019090300
Number of Individuals Covered	104
Insurance policy start date	2013-01-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $7,176
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 $239,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,176
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090901

Policy instance

Insurance contract or identification number	019090901
Number of Individuals Covered	29
Insurance policy start date	2013-08-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,294
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 $53,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,294
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090900

Policy instance

Insurance contract or identification number	019090900
Number of Individuals Covered	0
Insurance policy start date	2013-01-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $21
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 $689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090301

Policy instance

Insurance contract or identification number	019090301
Number of Individuals Covered	88
Insurance policy start date	2013-08-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,159
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 $244,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,159
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090901

Policy instance

Insurance contract or identification number	019090901
Number of Individuals Covered	8
Insurance policy start date	2013-01-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $453
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 $15,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $453
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090301

Policy instance

Insurance contract or identification number	019090301
Number of Individuals Covered	122
Insurance policy start date	2013-01-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $10,803
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 $360,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,803
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

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

Policy contract number

00479690

Policy instance

Insurance contract or identification number	00479690
Number of Individuals Covered	129
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,807
Total amount of fees paid to insurance company	USD $2,612
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,807
Amount paid for insurance broker fees	2612
Insurance broker organization code?	3
Insurance broker name	PATRICIA M. CUMMINGS

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0105493

Policy instance

Insurance contract or identification number	0105493
Number of Individuals Covered	166
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
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $69,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090300

Policy instance

Insurance contract or identification number	019090300
Number of Individuals Covered	96
Insurance policy start date	2013-08-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,518
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 $180,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,518
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

019090900

Policy instance

Insurance contract or identification number	019090900
Number of Individuals Covered	11
Insurance policy start date	2013-08-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $456
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 $18,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $456
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

019090301

Policy instance

Insurance contract or identification number	019090301
Number of Individuals Covered	120
Insurance policy start date	2012-08-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,458
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 $248,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,458
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

019090300

Policy instance

Insurance contract or identification number	019090300
Number of Individuals Covered	105
Insurance policy start date	2012-08-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,086
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 $169,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,086
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1089

Policy instance

Insurance contract or identification number	1089
Number of Individuals Covered	127
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-01
Total amount of commissions paid to insurance broker	USD $211
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
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $211
Insurance broker organization code?	3
Insurance broker name	M. SUZANNE TRACEY

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

Policy contract number

00479690

Policy instance

Insurance contract or identification number	00479690
Number of Individuals Covered	131
Insurance policy start date	2012-08-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,703
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,703
Insurance broker organization code?	3
Insurance broker name	PATRICIA M. CUMMINGS

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

Policy contract number

252023-000-001

Policy instance

Insurance contract or identification number	252023-000-001
Number of Individuals Covered	269
Insurance policy start date	2012-01-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $1,726
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,726
Insurance broker organization code?	3
Insurance broker name	M. SUZANNE TRACEY

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

Policy contract number

14285

Policy instance

Insurance contract or identification number	14285
Number of Individuals Covered	234
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $12,832
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 $635,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,832
Insurance broker organization code?	3
Insurance broker name	M. SUZANNE TRACEY

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

Policy contract number

14285

Policy instance

Insurance contract or identification number	14285
Number of Individuals Covered	234
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,930
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $95,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,930
Insurance broker organization code?	3
Insurance broker name	M. SUZANNE TRACEY

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0105493

Policy instance

Insurance contract or identification number	0105493
Number of Individuals Covered	178
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
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $66,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

019090901

Policy instance

Insurance contract or identification number	019090901
Number of Individuals Covered	4
Insurance policy start date	2012-08-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $189
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 $6,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $189
Insurance broker organization code?	3
Insurance broker name	TRACEY & ASSOCIATES

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1089

Policy instance

Insurance contract or identification number	1089
Number of Individuals Covered	128
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $362
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
Vision Insurance Welfare Benefit	Yes
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

14285

Policy instance

Insurance contract or identification number	14285
Number of Individuals Covered	235
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $22,301
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 $1,081,193
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

14285

Policy instance

Insurance contract or identification number	14285
Number of Individuals Covered	235
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,183
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $159,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0105493

Policy instance

Insurance contract or identification number	0105493
Number of Individuals Covered	177
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
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $63,736
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

252023-000-001

Policy instance

Insurance contract or identification number	252023-000-001
Number of Individuals Covered	282
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,766
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,728
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

14285

Policy instance

Insurance contract or identification number	14285
Number of Individuals Covered	243
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,523
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $186,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0105493

Policy instance

Insurance contract or identification number	0105493
Number of Individuals Covered	181
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 $11
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $57,692
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

252023-000-001

Policy instance

Insurance contract or identification number	252023-000-001
Number of Individuals Covered	284
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
Welfare Benefit Premiums Paid to Carrier	USD $70,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1089

Policy instance

Insurance contract or identification number	1089
Number of Individuals Covered	132
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $286
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
Vision Insurance Welfare Benefit	Yes
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

14285

Policy instance

Insurance contract or identification number	14285
Number of Individuals Covered	243
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $14,635
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 $976,356
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	OBSERVER PUBLISHING COMPANY
Employer identification number (EIN):	250699690
NAIC Classification:	511110
NAIC Description:	Newspaper Publishers

Jurisdiction of Incorporation:	Georgia Department of States Corporations Division
Incorporation Date:
Company Identification Number:	451187

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
502	2018-01-01	DAVID F. LYLE	2019-08-20
502	2017-01-01
502	2016-01-01
502	2015-01-01
502	2014-01-01
502	2013-01-01
502	2012-01-01	DAVID F. LYLE, CFO
502	2011-01-01	DAVID F. LYLE, CFO
502	2010-01-01	DAVID F. LYLE, CFO
502	2009-01-01	DAVID F. LYLE, CFO