401k Plan data: LUTHERAN HOME EMPLOYEE BENEFIT PLAN plan

LUTHERAN HOME EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	LUTHERAN HOME EMPLOYEE BENEFIT PLAN
Plan identification number	501

LUTHERAN HOME EMPLOYEE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Other welfare benefit cover

401k Sponsoring company profile

LUTHERAN HOME AT KANE has sponsored the creation of one or more 401k plans.

Company Name: LUTHERAN HOME AT KANE

Employer identification number (EIN): 251158827

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LUTHERAN HOME EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-01-01 CHARLOTTE FLORAVIT JESSICA COPENHAVER 2016-07-25
501 2014-01-01 MEGAN BOLDEN MEGAN BOLDEN 2015-07-30
501 2013-01-01 LINDA D CARLSON LINDA D CARLSON 2014-05-15
501 2012-01-01 LINDA D CARLSON LINDA D CARLSON 2013-05-09
501 2011-01-01 LINDA D CARLSON LINDA D CARLSON 2012-10-29
501 2010-01-01 LINDA D CARLSON LINDA D CARLSON 2011-06-27
501 2009-01-01 CHESTER SANDERSON
501 2009-01-01 LINDA D. CARLSON LINDA D CARLSON 2010-08-31

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2015-01-01	CHARLOTTE FLORAVIT	JESSICA COPENHAVER	2016-07-25
501	2014-01-01	MEGAN BOLDEN	MEGAN BOLDEN	2015-07-30
501	2013-01-01	LINDA D CARLSON	LINDA D CARLSON	2014-05-15
501	2012-01-01	LINDA D CARLSON	LINDA D CARLSON	2013-05-09
501	2011-01-01	LINDA D CARLSON	LINDA D CARLSON	2012-10-29
501	2010-01-01	LINDA D CARLSON	LINDA D CARLSON	2011-06-27
501	2009-01-01	CHESTER SANDERSON
501	2009-01-01	LINDA D. CARLSON	LINDA D CARLSON	2010-08-31

Plan Statistics for LUTHERAN HOME EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for LUTHERAN HOME EMPLOYEE BENEFIT PLAN

Measure Date Value
2015: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 105
Number of retired or separated participants receiving benefits 2015-01-01 1
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 106
2014: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 108
Number of retired or separated participants receiving benefits 2014-01-01 1
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 109
2013: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 132
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 125
Total of all active and inactive participants 2013-01-01 125
2012: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 131
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 132
Total of all active and inactive participants 2012-01-01 132
2011: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 136
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 131
Total of all active and inactive participants 2011-01-01 131
2010: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 131
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 136
Total of all active and inactive participants 2010-01-01 136
2009: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 124
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 124
Total of all active and inactive participants 2009-01-01 124
Total participants 2009-01-01 124

Measure	Date	Value
2015: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	105
Number of retired or separated participants receiving benefits	2015-01-01	1
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	106
2014: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	108
Number of retired or separated participants receiving benefits	2014-01-01	1
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	109
2013: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	132
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	125
Total of all active and inactive participants	2013-01-01	125
2012: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	131
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	132
Total of all active and inactive participants	2012-01-01	132
2011: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	136
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	131
Total of all active and inactive participants	2011-01-01	131
2010: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	131
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	136
Total of all active and inactive participants	2010-01-01	136
2009: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	124
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	124
Total of all active and inactive participants	2009-01-01	124
Total participants	2009-01-01	124

Form 5500 Responses for LUTHERAN HOME EMPLOYEE BENEFIT PLAN

2015: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: LUTHERAN HOME EMPLOYEE BENEFIT 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 benefit arrangement – Insurance	Yes
2010: LUTHERAN HOME EMPLOYEE BENEFIT 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 benefit arrangement – Insurance	Yes
2009: LUTHERAN HOME EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

021009900

Policy instance

Insurance contract or identification number	021009900
Number of Individuals Covered	2
Insurance policy start date	2015-04-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $160
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $160
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONSULTANTS, INC.

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

Policy contract number

00471049

Policy instance

Insurance contract or identification number	00471049
Number of Individuals Covered	41
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,398
Total amount of fees paid to insurance company	USD $1,354
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,351
Amount paid for insurance broker fees	1354
Insurance broker organization code?	3
Insurance broker name	LIFETIME FINANCIAL GROWTH, LLC

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G 00609308

Policy instance

Insurance contract or identification number	G 00609308
Number of Individuals Covered	105
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,333
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $25,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,333
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONSULTANTS, INC.

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

Policy contract number

021009300

Policy instance

Insurance contract or identification number	021009300
Number of Individuals Covered	96
Insurance policy start date	2015-01-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $3,740
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $171,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,740
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONSULTANTS, INC.

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

Policy contract number

021009300

Policy instance

Insurance contract or identification number	021009300
Number of Individuals Covered	94
Insurance policy start date	2015-04-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,738
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $335,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,738
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONSULTANTS, INC.

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

Policy contract number

021009900

Policy instance

Insurance contract or identification number	021009900
Number of Individuals Covered	2
Insurance policy start date	2015-01-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $148
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,578
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $148
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONSULTANTS, INC.

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G 00609308

Policy instance

Insurance contract or identification number	G 00609308
Number of Individuals Covered	109
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,434
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $27,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,434
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONSULTANTS, INC.

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

Policy contract number

021009900

Policy instance

Insurance contract or identification number	021009900
Number of Individuals Covered	4
Insurance policy start date	2014-04-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $107
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $107
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONSULTANTS, INC.

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

Policy contract number

021009300

Policy instance

Insurance contract or identification number	021009300
Number of Individuals Covered	95
Insurance policy start date	2014-04-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $10,546
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $393,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,546
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONSULTANTS, INC.

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

Policy contract number

00471049

Policy instance

Insurance contract or identification number	00471049
Number of Individuals Covered	53
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,499
Total amount of fees paid to insurance company	USD $1,645
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,450
Amount paid for insurance broker fees	1645
Insurance broker organization code?	3
Insurance broker name	LIFETIME FINANCIAL GROWTH, LLC

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

Policy contract number

6181650000

Policy instance

Insurance contract or identification number	6181650000
Number of Individuals Covered	96
Insurance policy start date	2014-01-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $4,325
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $133,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,325
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONSULTANTS, INC.

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

Policy contract number

00471049

Policy instance

Insurance contract or identification number	00471049
Number of Individuals Covered	56
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,287
Total amount of fees paid to insurance company	USD $1,834
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,236
Amount paid for insurance broker fees	1834
Insurance broker organization code?	3
Insurance broker name	LIFETIME FINANCIAL GROWTH, LLC

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

Policy contract number

6181650000

Policy instance

Insurance contract or identification number	6181650000
Number of Individuals Covered	99
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $18,338
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $564,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,338
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONULTANTS, INC.

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G 00609308

Policy instance

Insurance contract or identification number	G 00609308
Number of Individuals Covered	121
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,508
Total amount of fees paid to insurance company	USD $274
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $29,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,508
Amount paid for insurance broker fees	274
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONSULTANTS, INC.

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

Policy contract number

01068413

Policy instance

Insurance contract or identification number	01068413
Insurance policy start date	2012-01-01
Insurance policy end date	2012-03-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,677
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	BABB, INC.

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

Policy contract number

00471049

Policy instance

Insurance contract or identification number	00471049
Number of Individuals Covered	57
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,534
Total amount of fees paid to insurance company	USD $331
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,388
Amount paid for insurance broker fees	331
Insurance broker organization code?	3
Insurance broker name	LIFETIME FINANCIAL GROWTH, LLC

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

Policy contract number

6181650000

Policy instance

Insurance contract or identification number	6181650000
Number of Individuals Covered	100
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $18,580
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $583,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,580
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONULTANTS, INC.

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G 00609308

Policy instance

Insurance contract or identification number	G 00609308
Number of Individuals Covered	132
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,399
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $27,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,399
Insurance broker organization code?	3
Insurance broker name	DAVEVIC BENEFIT CONSULTANTS, INC.

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

Policy contract number

901851800

Policy instance

Insurance contract or identification number	901851800
Insurance policy start date	2011-01-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $2,538
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,948
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

901851902

Policy instance

Insurance contract or identification number	901851902
Insurance policy start date	2011-01-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $60
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )

Policy contract number

680322

Policy instance

Insurance contract or identification number	680322
Number of Individuals Covered	39
Insurance policy start date	2011-01-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $851
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

01068413

Policy instance

Insurance contract or identification number	01068413
Number of Individuals Covered	134
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G 00609308

Policy instance

Insurance contract or identification number	G 00609308
Number of Individuals Covered	131
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,259
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $24,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

6181650000

Policy instance

Insurance contract or identification number	6181650000
Number of Individuals Covered	106
Insurance policy start date	2011-04-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $13,405
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $446,812
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

901851801

Policy instance

Insurance contract or identification number	901851801
Insurance policy start date	2011-01-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $2,494
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,841
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

901851300

Policy instance

Insurance contract or identification number	901851300
Insurance policy start date	2011-01-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $1,087
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,167
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

Policy instance

Number of Individuals Covered	47
Insurance policy start date	2011-10-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $509
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

01068413

Policy instance

Insurance contract or identification number	01068413
Number of Individuals Covered	134
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,622
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	BABB, INC.

HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )

Policy contract number

680322

Policy instance

Insurance contract or identification number	680322
Number of Individuals Covered	40
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,359
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,359
Insurance broker organization code?	3
Insurance broker name	BABB, INC.

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

Policy contract number

901851902

Policy instance

Insurance contract or identification number	901851902
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $180
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $180
Insurance broker organization code?	3
Insurance broker name	BABB, INC.

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

Policy contract number

901851800

Policy instance

Insurance contract or identification number	901851800
Number of Individuals Covered	44
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $9,108
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $227,698
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,108
Insurance broker organization code?	3
Insurance broker name	BABB, INC.

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

Policy contract number

901851801

Policy instance

Insurance contract or identification number	901851801
Number of Individuals Covered	44
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $9,869
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $246,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,869
Insurance broker organization code?	3
Insurance broker name	BABB, INC.

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

Policy contract number

901851300

Policy instance

Insurance contract or identification number	901851300
Number of Individuals Covered	15
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,645
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,645
Insurance broker organization code?	3
Insurance broker name	BABB, INC.

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G 00609308

Policy instance

Insurance contract or identification number	G 00609308
Number of Individuals Covered	136
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,240
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $24,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,240
Insurance broker organization code?	3
Insurance broker name	BABB, INC.

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Company Name:	LUTHERAN HOME AT KANE
Employer identification number (EIN):	251158827
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities