WOLTZ & WIND FORD WELFARE PLAN 401k Plan overview

Plan Name	WOLTZ & WIND FORD WELFARE PLAN
Plan identification number	506

WOLTZ & WIND FORD WELFARE 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) Long-term disability cover

401k Sponsoring company profile

WOLTZ & WIND FORD, INC. has sponsored the creation of one or more 401k plans.

Company Name:	WOLTZ & WIND FORD, INC.
Employer identification number (EIN):	251353793
NAIC Classification:	441110
NAIC Description:	New Car Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WOLTZ & WIND FORD WELFARE PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
506	2022-01-01
506	2021-01-01	DANIEL L WIND	2022-07-15	DANIEL L WIND	2022-07-15
506	2020-01-01	DANIEL L. WIND	2021-10-14	DANIEL L. WIND	2021-10-14
506	2019-01-01	LAWRENCE WIND	2020-10-09	LAWRENCE WIND	2020-10-09
506	2018-01-01	LAWRENCE WIND	2019-10-12	LAWRENCE WIND	2019-10-12
506	2017-01-01
506	2016-01-01
506	2015-01-01
506	2014-01-01
506	2013-01-01
506	2012-01-01	LAWRENCE WIND
506	2011-01-01	LAWRENCE WIND
506	2009-01-01	LAWRENCE WIND

Plan Statistics for WOLTZ & WIND FORD WELFARE PLAN

401k plan membership statisitcs for WOLTZ & WIND FORD WELFARE PLAN

Measure	Date	Value
2022: WOLTZ & WIND FORD WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	113
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	113
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	113
2021: WOLTZ & WIND FORD WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	136
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	117
Number of retired or separated participants receiving benefits	2021-01-01	1
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	118
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	118
Number of participants with account balances	2021-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
Number of employers contributing to the scheme	2021-01-01	0
2020: WOLTZ & WIND FORD WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	136
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	128
Number of retired or separated participants receiving benefits	2020-01-01	8
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	136
Total participants	2020-01-01	136
2019: WOLTZ & WIND FORD WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	135
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	136
Number of retired or separated participants receiving benefits	2019-01-01	1
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	137
Total participants	2019-01-01	137
2018: WOLTZ & WIND FORD WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	138
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	135
Total of all active and inactive participants	2018-01-01	135
Total participants	2018-01-01	135
2017: WOLTZ & WIND FORD WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	126
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	138
Total of all active and inactive participants	2017-01-01	138
Total participants	2017-01-01	138
2016: WOLTZ & WIND FORD WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	126
Total of all active and inactive participants	2016-01-01	126
Total participants	2016-01-01	126
2015: WOLTZ & WIND FORD WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	123
Number of retired or separated participants receiving benefits	2015-01-01	0
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	123
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	123
2014: WOLTZ & WIND FORD WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	262
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	129
Number of retired or separated participants receiving benefits	2014-01-01	0
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	129
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	129
2013: WOLTZ & WIND FORD WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	247
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	262
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	262
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	262
Number of participants with account balances	2013-01-01	262
2012: WOLTZ & WIND FORD WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	247
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	247
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	247
Number of participants with account balances	2012-01-01	247
2011: WOLTZ & WIND FORD WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	118
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	118
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	118
Number of participants with account balances	2011-01-01	118
2009: WOLTZ & WIND FORD WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	118
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	118
Total participants	2009-01-01	118

Form 5500 Responses for WOLTZ & WIND FORD WELFARE PLAN

2022: WOLTZ & WIND FORD WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: WOLTZ & WIND FORD WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: WOLTZ & WIND FORD WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: WOLTZ & WIND FORD WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: WOLTZ & WIND FORD WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: WOLTZ & WIND FORD 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 benefit arrangement – Insurance	Yes
2016: WOLTZ & WIND FORD 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 benefit arrangement – Insurance	Yes
2015: WOLTZ & WIND FORD 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 benefit arrangement – Insurance	Yes
2014: WOLTZ & WIND FORD 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 benefit arrangement – Insurance	Yes
2013: WOLTZ & WIND FORD 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 benefit arrangement – Insurance	Yes
2012: WOLTZ & WIND FORD WELFARE 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: WOLTZ & WIND FORD WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: WOLTZ & WIND FORD WELFARE 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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA1
Policy instance	30
Insurance contract or identification number 010128AA1 Number of Individuals Covered 51 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $1,729 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,712 Commission paid to Insurance Broker USD $1,729 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128918
Policy instance	14
Insurance contract or identification number 010128918 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $41 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $956 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $41 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128917
Policy instance	13
Insurance contract or identification number 010128917 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 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
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128916
Policy instance	12
Insurance contract or identification number 010128916 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 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
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128915
Policy instance	11
Insurance contract or identification number 010128915 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $68 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,257 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $68 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128809
Policy instance	9
Insurance contract or identification number 010128809 Number of Individuals Covered 33 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $4,605 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $153,999 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,605 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128808
Policy instance	8
Insurance contract or identification number 010128808 Number of Individuals Covered 40 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $5,734 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $192,241 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,734 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128807
Policy instance	7
Insurance contract or identification number 010128807 Number of Individuals Covered 43 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $6,276 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $205,356 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,276 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128806
Policy instance	6
Insurance contract or identification number 010128806 Number of Individuals Covered 77 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $10,619 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $360,496 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,619 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128311
Policy instance	5
Insurance contract or identification number 010128311 Number of Individuals Covered 10 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $1,129 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $36,815 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,129 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128310
Policy instance	4
Insurance contract or identification number 010128310 Number of Individuals Covered 7 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $1,189 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $40,810 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,189 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128309
Policy instance	3
Insurance contract or identification number 010128309 Number of Individuals Covered 7 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $1,053 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $31,697 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,053 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128308
Policy instance	2
Insurance contract or identification number 010128308 Number of Individuals Covered 4 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $1,059 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $33,518 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,059 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7002686
Policy instance	1
Insurance contract or identification number E7002686 Number of Individuals Covered 2 Insurance policy start date 2022-03-01 Insurance policy end date 2023-02-28 Total amount of commissions paid to insurance broker USD $15 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $301 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128919
Policy instance	15
Insurance contract or identification number 010128919 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 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
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128920
Policy instance	16
Insurance contract or identification number 010128920 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 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
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128914
Policy instance	10
Insurance contract or identification number 010128914 Number of Individuals Covered 2 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $88 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,029 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $88 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	STD
Policy instance	29
Insurance contract or identification number STD Number of Individuals Covered 1 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of fees paid to insurance company USD $24 Other welfare benefits provided SHORT-TERM DISABILITY Welfare Benefit Premiums Paid to Carrier USD $5,336 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 24 Additional information about fees paid to insurance broker TPA FEES Insurance broker organization code? 5
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	MEDICAL GROUP
Policy instance	28
Insurance contract or identification number MEDICAL GROUP Number of Individuals Covered 18 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $81 Total amount of fees paid to insurance company USD $35 Health Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,286 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $81 Insurance broker organization code? 3 Amount paid for insurance broker fees 35 Additional information about fees paid to insurance broker TPA FEES
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	CANCER
Policy instance	27
Insurance contract or identification number CANCER Number of Individuals Covered 6 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $514 Total amount of fees paid to insurance company USD $114 Other welfare benefits provided CANCER COVERAGE Welfare Benefit Premiums Paid to Carrier USD $2,609 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $514 Insurance broker organization code? 3 Amount paid for insurance broker fees 114 Additional information about fees paid to insurance broker TPA FEES
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	LTD
Policy instance	26
Insurance contract or identification number LTD Number of Individuals Covered 51 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $499 Total amount of fees paid to insurance company USD $3,316 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $83,833 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $499 Insurance broker organization code? 3 Amount paid for insurance broker fees 3316 Additional information about fees paid to insurance broker TPA FEES
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	GROUP HI/GAP
Policy instance	25
Insurance contract or identification number GROUP HI/GAP Number of Individuals Covered 11 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Insurance broker organization code? 3 Additional information about fees paid to insurance broker THIRD PARTY ADMIN
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	ACCIDENT
Policy instance	24
Insurance contract or identification number ACCIDENT Number of Individuals Covered 24 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $796 Total amount of fees paid to insurance company USD $397 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,769 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $796 Insurance broker organization code? 3 Amount paid for insurance broker fees 397 Additional information about fees paid to insurance broker AGENT FEE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	LIFE ADD
Policy instance	23
Insurance contract or identification number LIFE ADD Number of Individuals Covered 162 Insurance policy start date 2021-01-01 Insurance policy end date 2022-01-01 Total amount of commissions paid to insurance broker USD $704 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,041 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $704 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128CA2
Policy instance	22
Insurance contract or identification number 010128CA2 Number of Individuals Covered 3 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $85 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,003 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $85 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128CA0
Policy instance	21
Insurance contract or identification number 010128CA0 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $8 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $80 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA3
Policy instance	20
Insurance contract or identification number 010128AA3 Number of Individuals Covered 49 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $1,675 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $16,529 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,675 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA2
Policy instance	19
Insurance contract or identification number 010128AA2 Number of Individuals Covered 25 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $804 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,909 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $804 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA0
Policy instance	18
Insurance contract or identification number 010128AA0 Number of Individuals Covered 48 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $1,219 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,712 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,219 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128921
Policy instance	17
Insurance contract or identification number 010128921 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 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
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	STD
Policy instance	9
Insurance contract or identification number STD Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $-126 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,215 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $-126 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128803
Policy instance	10
Insurance contract or identification number 010128803 Number of Individuals Covered 53 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $7,013 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $232,127 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,013 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128806
Policy instance	11
Insurance contract or identification number 010128806 Number of Individuals Covered 63 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $7,467 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $245,567 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,467 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128906
Policy instance	12
Insurance contract or identification number 010128906 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $14 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $457 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128805
Policy instance	13
Insurance contract or identification number 010128805 Number of Individuals Covered 36 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $5,119 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $168,639 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,119 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128907
Policy instance	14
Insurance contract or identification number 010128907 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $12 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 $12 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128307
Policy instance	8
Insurance contract or identification number 010128307 Number of Individuals Covered 11 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $1,109 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $38,553 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,109 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128306
Policy instance	7
Insurance contract or identification number 010128306 Number of Individuals Covered 8 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $1,355 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $45,155 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,355 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128305
Policy instance	6
Insurance contract or identification number 010128305 Number of Individuals Covered 18 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $1,957 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $65,604 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,957 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128CA2
Policy instance	5
Insurance contract or identification number 010128CA2 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $75 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA3
Policy instance	4
Insurance contract or identification number 010128AA3 Number of Individuals Covered 47 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $1,227 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,220 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,227 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128304
Policy instance	3
Insurance contract or identification number 010128304 Number of Individuals Covered 4 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $722 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $23,614 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $722 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128807
Policy instance	2
Insurance contract or identification number 010128807 Number of Individuals Covered 51 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $5,345 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $173,694 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,345 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128911
Policy instance	1
Insurance contract or identification number 010128911 Number of Individuals Covered 1 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $272 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $9,062 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $272 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128909
Policy instance	15
Insurance contract or identification number 010128909 Number of Individuals Covered 2 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $335 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,027 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $335 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128912
Policy instance	16
Insurance contract or identification number 010128912 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $37 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,232 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $37 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA0
Policy instance	18
Insurance contract or identification number 010128AA0 Number of Individuals Covered 53 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $1,074 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $10,787 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,074 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	01012CA1
Policy instance	30
Insurance contract or identification number 01012CA1 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $15 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $228 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	01012CA0
Policy instance	29
Insurance contract or identification number 01012CA0 Number of Individuals Covered 1 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $37 Welfare Benefit Premiums Paid to Carrier USD $224 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $37 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	MEDICAL GROUP
Policy instance	27
Insurance contract or identification number MEDICAL GROUP Number of Individuals Covered 15 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $103 Other welfare benefits provided MEDICAL GROUP Welfare Benefit Premiums Paid to Carrier USD $1,052 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $75 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	LTD
Policy instance	26
Insurance contract or identification number LTD Number of Individuals Covered 57 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $5,866 Health Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $81,699 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,289 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	GROUP HI/GAP
Policy instance	25
Insurance contract or identification number GROUP HI/GAP Number of Individuals Covered 14 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Welfare Benefit Premiums Paid to Carrier USD $5,607 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	CANCER
Policy instance	24
Insurance contract or identification number CANCER Number of Individuals Covered 6 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $105 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,398 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $105 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	ACCIDENT
Policy instance	23
Insurance contract or identification number ACCIDENT Number of Individuals Covered 27 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $660 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,840 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
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128914
Policy instance	17
Insurance contract or identification number 010128914 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $180 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,009 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
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7002686
Policy instance	28
Insurance contract or identification number E7002686 Number of Individuals Covered 3 Insurance policy start date 2020-03-01 Insurance policy end date 2021-02-28 Total amount of commissions paid to insurance broker USD $40 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,035 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA1
Policy instance	19
Insurance contract or identification number 010128AA1 Number of Individuals Covered 65 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $1,799 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $17,975 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,799 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA2
Policy instance	20
Insurance contract or identification number 010128AA2 Number of Individuals Covered 34 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $765 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,422 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $765 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128CA3
Policy instance	21
Insurance contract or identification number 010128CA3 Number of Individuals Covered 1 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $38 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $765 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $38 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128915
Policy instance	22
Insurance contract or identification number 010128915 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $120 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,016 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $120 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128803
Policy instance	10
Insurance contract or identification number 010128803 Number of Individuals Covered 58 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $7,798 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $260,833 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,798 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	STD
Policy instance	9
Insurance contract or identification number STD Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $243 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,069 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $243 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128307
Policy instance	8
Insurance contract or identification number 010128307 Number of Individuals Covered 7 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $884 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $26,568 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $884 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128306
Policy instance	7
Insurance contract or identification number 010128306 Number of Individuals Covered 8 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $1,289 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $43,653 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,289 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128305
Policy instance	6
Insurance contract or identification number 010128305 Number of Individuals Covered 17 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $2,449 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $78,670 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,449 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128CA3
Policy instance	5
Insurance contract or identification number 010128CA3 Number of Individuals Covered 1 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $28 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $304 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA3
Policy instance	4
Insurance contract or identification number 010128AA3 Number of Individuals Covered 41 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $1,338 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,603 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,338 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128304
Policy instance	3
Insurance contract or identification number 010128304 Number of Individuals Covered 5 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $910 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $30,571 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $910 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128807
Policy instance	2
Insurance contract or identification number 010128807 Number of Individuals Covered 63 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $7,216 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $261,029 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,216 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128911
Policy instance	1
Insurance contract or identification number 010128911 Number of Individuals Covered 1 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $136 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,948 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $136 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128806
Policy instance	11
Insurance contract or identification number 010128806 Number of Individuals Covered 72 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $8,038 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $293,444 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,038 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128805
Policy instance	12
Insurance contract or identification number 010128805 Number of Individuals Covered 41 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $5,807 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $195,858 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,807 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128909
Policy instance	13
Insurance contract or identification number 010128909 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 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
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7002686
Policy instance	23
Insurance contract or identification number E7002686 Number of Individuals Covered 3 Insurance policy start date 2020-03-01 Insurance policy end date 2021-02-28 Total amount of commissions paid to insurance broker USD $39 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,035 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $39 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	MEDICAL GROUP
Policy instance	22
Insurance contract or identification number MEDICAL GROUP Number of Individuals Covered 21 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $-28 Total amount of fees paid to insurance company USD $43 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,683 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $-28 Amount paid for insurance broker fees 43 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	LTD
Policy instance	21
Insurance contract or identification number LTD Number of Individuals Covered 60 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $3,906 Total amount of fees paid to insurance company USD $3,829 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $83,189 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,906 Amount paid for insurance broker fees 3829 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	CANCER
Policy instance	19
Insurance contract or identification number CANCER Number of Individuals Covered 5 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $105 Total amount of fees paid to insurance company USD $94 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,129 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $105 Amount paid for insurance broker fees 94 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	GROUP HI/GAP
Policy instance	20
Insurance contract or identification number GROUP HI/GAP Number of Individuals Covered 15 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $76 Welfare Benefit Premiums Paid to Carrier USD $4,633 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $76 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	ACCIDENT
Policy instance	18
Insurance contract or identification number ACCIDENT Number of Individuals Covered 19 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $648 Total amount of fees paid to insurance company USD $378 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,733 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $648 Amount paid for insurance broker fees 378 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128CA2
Policy instance	17
Insurance contract or identification number 010128CA2 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $-51 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA2
Policy instance	16
Insurance contract or identification number 010128AA2 Number of Individuals Covered 49 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $1,098 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,057 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,098 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA1
Policy instance	15
Insurance contract or identification number 010128AA1 Number of Individuals Covered 66 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $2,134 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $21,210 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,134 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA0
Policy instance	14
Insurance contract or identification number 010128AA0 Number of Individuals Covered 49 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $1,175 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,290 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,175 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128805
Policy instance	10
Insurance contract or identification number 010128805 Number of Individuals Covered 40 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $5,552 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $185,993 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,552 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128909
Policy instance	11
Insurance contract or identification number 010128909 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $116 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,484 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $116 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number
Policy instance	19
Number of Individuals Covered 30 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of fees paid to insurance company USD $39 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,472 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 39 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number
Policy instance	18
Number of Individuals Covered 64 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $869 Total amount of fees paid to insurance company USD $2,826 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $60,061 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $869 Amount paid for insurance broker fees 2826 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA3
Policy instance	2
Insurance contract or identification number 010128AA3 Number of Individuals Covered 34 Insurance policy start date 2018-05-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $1,024 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,420 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,024 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number
Policy instance	16
Number of Individuals Covered 25 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $-26 Total amount of fees paid to insurance company USD $320 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,792 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $-26 Amount paid for insurance broker fees 320 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128CA2
Policy instance	15
Insurance contract or identification number 010128CA2 Insurance policy start date 2018-05-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $3 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $51 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 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA2
Policy instance	14
Insurance contract or identification number 010128AA2 Number of Individuals Covered 45 Insurance policy start date 2018-05-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $912 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $9,870 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $912 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA1
Policy instance	13
Insurance contract or identification number 010128AA1 Number of Individuals Covered 70 Insurance policy start date 2018-05-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $1,925 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $21,150 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,925 Insurance broker organization code? 3
UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )
Policy contract number	010128AA0
Policy instance	12
Insurance contract or identification number 010128AA0 Number of Individuals Covered 55 Insurance policy start date 2018-05-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $1,063 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,823 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,063 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number
Policy instance	20
Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $108 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,767 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $108 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7002686
Policy instance	21
Insurance contract or identification number E7002686 Number of Individuals Covered 3 Insurance policy start date 2019-03-01 Insurance policy end date 2020-02-29 Total amount of commissions paid to insurance broker USD $103 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $821 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $103 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128803
Policy instance	8
Insurance contract or identification number 010128803 Number of Individuals Covered 64 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $7,742 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $258,444 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,742 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128304
Policy instance	1
Insurance contract or identification number 010128304 Number of Individuals Covered 5 Insurance policy start date 2018-05-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $853 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $28,527 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $853 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128CA1
Policy instance	3
Insurance contract or identification number 010128CA1 Insurance policy start date 2018-05-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $23 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $203 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128305
Policy instance	4
Insurance contract or identification number 010128305 Number of Individuals Covered 23 Insurance policy start date 2018-05-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $2,451 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $85,311 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,451 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128306
Policy instance	5
Insurance contract or identification number 010128306 Number of Individuals Covered 8 Insurance policy start date 2018-05-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $1,744 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $57,166 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,744 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128307
Policy instance	6
Insurance contract or identification number 010128307 Number of Individuals Covered 8 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $1,428 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $48,606 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,428 Insurance broker organization code? 3
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number
Policy instance	17
Number of Individuals Covered 6 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $-8 Total amount of fees paid to insurance company USD $79 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,617 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $-8 Amount paid for insurance broker fees 79 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128802
Policy instance	7
Insurance contract or identification number 010128802 Number of Individuals Covered 63 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $7,414 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $250,434 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,414 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128804
Policy instance	9
Insurance contract or identification number 010128804 Number of Individuals Covered 63 Insurance policy start date 2018-04-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $6,234 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $209,666 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,234 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128805
Policy instance	10
Insurance contract or identification number 010128805 Number of Individuals Covered 41 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $4,664 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $156,988 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,664 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128804
Policy instance	9
Insurance contract or identification number 010128804 Number of Individuals Covered 57 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $5,820 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $197,390 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,820 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128907
Policy instance	8
Insurance contract or identification number 010128907 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $31 Welfare Benefit Premiums Paid to Carrier USD $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 $31 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128909
Policy instance	11
Insurance contract or identification number 010128909 Number of Individuals Covered 1 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $45 Welfare Benefit Premiums Paid to Carrier USD $1,872 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $45 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128803
Policy instance	7
Insurance contract or identification number 010128803 Number of Individuals Covered 62 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $7,528 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $252,526 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,528 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128802
Policy instance	6
Insurance contract or identification number 010128802 Number of Individuals Covered 59 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $7,137 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $236,850 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,137 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128307
Policy instance	5
Insurance contract or identification number 010128307 Number of Individuals Covered 12 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $2,064 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $67,218 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,064 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128306
Policy instance	4
Insurance contract or identification number 010128306 Number of Individuals Covered 10 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $1,840 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $60,964 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,840 Insurance broker organization code? 3
UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )
Policy contract number	2531
Policy instance	2
Insurance contract or identification number 2531 Number of Individuals Covered 133 Insurance policy start date 2018-01-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $214 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $9,661 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $214
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128304
Policy instance	1
Insurance contract or identification number 010128304 Number of Individuals Covered 5 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $1,155 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $37,530 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,155 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128305
Policy instance	3
Insurance contract or identification number 010128305 Number of Individuals Covered 18 Insurance policy start date 2017-04-01 Insurance policy end date 2018-03-31 Total amount of commissions paid to insurance broker USD $1,858 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $60,449 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,858 Insurance broker organization code? 3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128305
Policy instance	6
Insurance contract or identification number 010128305 Number of Individuals Covered 24 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $2,295 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $77,617 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,295 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP, LLC
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number	3156
Policy instance	5
Insurance contract or identification number 3156 Number of Individuals Covered 139 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $436 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,458 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $436 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )
Policy contract number	2531
Policy instance	4
Insurance contract or identification number 2531 Number of Individuals Covered 134 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $881 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $29,299 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $881 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP , LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128304
Policy instance	3
Insurance contract or identification number 010128304 Number of Individuals Covered 7 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $1,174 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $39,120 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,174 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0478043
Policy instance	2
Insurance contract or identification number 0478043 Number of Individuals Covered 178 Insurance policy start date 2016-06-01 Insurance policy end date 2017-05-31 Total amount of commissions paid to insurance broker USD $870 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $7,020 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $870 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	ACC CAN LTD STD
Policy instance	1
Insurance contract or identification number ACC CAN LTD STD Number of Individuals Covered 128 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $5,728 Total amount of fees paid to insurance company USD $1,409 Health Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $87,890 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $367 Amount paid for insurance broker fees 93 Additional information about fees paid to insurance broker PAA SERVICE FEE Insurance broker organization code? 3 Insurance broker name PENNSYLVANIA AUTO ASSOC INS AGY INC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128306
Policy instance	7
Insurance contract or identification number 010128306 Number of Individuals Covered 12 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $2,133 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $62,996 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,133 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP, LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128307
Policy instance	8
Insurance contract or identification number 010128307 Number of Individuals Covered 16 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $2,189 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $71,385 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,189 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP, LLC
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7002686
Policy instance	14
Insurance contract or identification number E7002686 Number of Individuals Covered 4 Insurance policy start date 2016-03-01 Insurance policy end date 2017-02-28 Total amount of commissions paid to insurance broker USD $114 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,492 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $114 Insurance broker name COLONIAL LIFE ACCIDENT INSURANCE CO
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128805
Policy instance	13
Insurance contract or identification number 010128805 Number of Individuals Covered 39 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $4,320 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $140,464 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,320 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP, LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128804
Policy instance	12
Insurance contract or identification number 010128804 Number of Individuals Covered 54 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $5,583 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $171,294 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,583 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP. LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128913
Policy instance	11
Insurance contract or identification number 010128913 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $91 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $91 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP INC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128803
Policy instance	10
Insurance contract or identification number 010128803 Number of Individuals Covered 61 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $7,010 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $236,852 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,010 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP, LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128802
Policy instance	9
Insurance contract or identification number 010128802 Number of Individuals Covered 65 Insurance policy start date 2016-04-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $6,624 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $220,363 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,624 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP, LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128911
Policy instance	13
Insurance contract or identification number 010128911 Number of Individuals Covered 7 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $52 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,081 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $52 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128805
Policy instance	12
Insurance contract or identification number 010128805 Number of Individuals Covered 28 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $2,921 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $113,993 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,921 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128804
Policy instance	11
Insurance contract or identification number 010128804 Number of Individuals Covered 54 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $5,550 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $198,998 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,550 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128803
Policy instance	10
Insurance contract or identification number 010128803 Number of Individuals Covered 60 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $6,619 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $239,638 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,619 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128802
Policy instance	9
Insurance contract or identification number 010128802 Number of Individuals Covered 61 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $7,172 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $255,020 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,172 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128307
Policy instance	8
Insurance contract or identification number 010128307 Number of Individuals Covered 12 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $1,387 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $44,781 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,387 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP, LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128306
Policy instance	7
Insurance contract or identification number 010128306 Number of Individuals Covered 12 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $2,008 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $70,362 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,008 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP, LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128305
Policy instance	6
Insurance contract or identification number 010128305 Number of Individuals Covered 22 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $2,248 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $81,415 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,248 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number	3156
Policy instance	5
Insurance contract or identification number 3156 Number of Individuals Covered 122 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $416 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 $416 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128304
Policy instance	3
Insurance contract or identification number 010128304 Number of Individuals Covered 8 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $1,444 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $52,062 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,444 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUGOAPHI
Policy instance	2
Insurance contract or identification number GLUGOAPHI Number of Individuals Covered 164 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $629 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,293 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $629 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	ACC CAN LTD STD
Policy instance	1
Insurance contract or identification number ACC CAN LTD STD Number of Individuals Covered 62 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $5,716 Total amount of fees paid to insurance company USD $1,206 Health Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $77,135 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,552 Amount paid for insurance broker fees 1206 Insurance broker organization code? 3 Insurance broker name AMERICAN FIDELITY ASSURANCE CO.
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number	010128913
Policy instance	14
Insurance contract or identification number 010128913 Number of Individuals Covered 1 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $139 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,936 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $139 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )
Policy contract number	2531
Policy instance	4
Insurance contract or identification number 2531 Number of Individuals Covered 62 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $766 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $25,393 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $766 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number	01174470
Policy instance	3
Insurance contract or identification number 01174470 Number of Individuals Covered 276 Insurance policy start date 2013-04-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $35,728 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $956,883 Commission paid to Insurance Broker USD $35,728 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	G000APH1
Policy instance	2
Insurance contract or identification number G000APH1 Number of Individuals Covered 164 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $633 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,332 Commission paid to Insurance Broker USD $633 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	ACC CAN LTD
Policy instance	1
Insurance contract or identification number ACC CAN LTD Number of Individuals Covered 57 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $5,622 Total amount of fees paid to insurance company USD $1,334 Health Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $75,395 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,724 Insurance broker organization code? 3 Amount paid for insurance broker fees 1334 Insurance broker name PAA SERVICES INC.
HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )
Policy contract number	5924850000
Policy instance	2
Insurance contract or identification number 5924850000 Number of Individuals Covered 262 Insurance policy start date 2012-04-01 Insurance policy end date 2013-03-31 Total amount of commissions paid to insurance broker USD $22,842 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $761,395 Commission paid to Insurance Broker USD $22,842 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	ACC CAN LTD
Policy instance	1
Insurance contract or identification number ACC CAN LTD Number of Individuals Covered 49 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $5,701 Total amount of fees paid to insurance company USD $1,137 Health Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $68,657 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,431 Insurance broker organization code? 3 Amount paid for insurance broker fees 1137 Insurance broker name PAA SERVICES INC.
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	ACC CAN LTD
Policy instance	1
Insurance contract or identification number ACC CAN LTD Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $5,756 Total amount of fees paid to insurance company USD $976 Health Insurance Welfare Benefit Yes Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $49,445 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,462 Insurance broker organization code? 3 Amount paid for insurance broker fees 976 Additional information about fees paid to insurance broker ADMIN Insurance broker name PAA SERVICES INC.
HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )
Policy contract number	5924850000
Policy instance	2
Insurance contract or identification number 5924850000 Number of Individuals Covered 242 Insurance policy start date 2011-04-01 Insurance policy end date 2012-03-31 Total amount of commissions paid to insurance broker USD $25,968 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $865,585 Commission paid to Insurance Broker USD $25,968 Insurance broker organization code? 3 Insurance broker name ENSCOE LONG INSURANCE GROUP LLC
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128302
Policy instance	8
Insurance contract or identification number 010128302 Number of Individuals Covered 1 Insurance policy start date 2010-04-01 Insurance policy end date 2010-03-31 Welfare Benefit Premiums Paid to Carrier USD $2,045
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128301
Policy instance	3
Insurance contract or identification number 010128301 Number of Individuals Covered 3 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Welfare Benefit Premiums Paid to Carrier USD $33,246
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128904
Policy instance	9
Insurance contract or identification number 010128904 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Welfare Benefit Premiums Paid to Carrier USD $2,570
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128303
Policy instance	10
Insurance contract or identification number 010128303 Number of Individuals Covered 3 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Welfare Benefit Premiums Paid to Carrier USD $28,564
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128900
Policy instance	11
Insurance contract or identification number 010128900 Number of Individuals Covered 1 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Welfare Benefit Premiums Paid to Carrier USD $3,925
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128902
Policy instance	7
Insurance contract or identification number 010128902 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Welfare Benefit Premiums Paid to Carrier USD $-998
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128901
Policy instance	6
Insurance contract or identification number 010128901 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Welfare Benefit Premiums Paid to Carrier USD $1,891
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128801
Policy instance	5
Insurance contract or identification number 010128801 Number of Individuals Covered 93 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Welfare Benefit Premiums Paid to Carrier USD $360,124
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128800
Policy instance	4
Insurance contract or identification number 010128800 Number of Individuals Covered 131 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Welfare Benefit Premiums Paid to Carrier USD $488,783
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128300
Policy instance	2
Insurance contract or identification number 010128300 Number of Individuals Covered 10 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Welfare Benefit Premiums Paid to Carrier USD $27,934
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	ALL CAN LTD
Policy instance	1
Insurance contract or identification number ALL CAN LTD Number of Individuals Covered 73 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $5,833 Total amount of fees paid to insurance company USD $994 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $47,874
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128901
Policy instance	6
Insurance contract or identification number 010128901 Number of Individuals Covered 1 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Welfare Benefit Premiums Paid to Carrier USD $7,426
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128801
Policy instance	5
Insurance contract or identification number 010128801 Number of Individuals Covered 75 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Welfare Benefit Premiums Paid to Carrier USD $293,094
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128800
Policy instance	4
Insurance contract or identification number 010128800 Number of Individuals Covered 116 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Welfare Benefit Premiums Paid to Carrier USD $390,626
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128301
Policy instance	3
Insurance contract or identification number 010128301 Number of Individuals Covered 8 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Welfare Benefit Premiums Paid to Carrier USD $40,464
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128300
Policy instance	2
Insurance contract or identification number 010128300 Number of Individuals Covered 10 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Welfare Benefit Premiums Paid to Carrier USD $24,782
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128303
Policy instance	8
Insurance contract or identification number 010128303 Number of Individuals Covered 8 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Welfare Benefit Premiums Paid to Carrier USD $6,157
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128904
Policy instance	9
Insurance contract or identification number 010128904 Number of Individuals Covered 2 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Welfare Benefit Premiums Paid to Carrier USD $16,176
AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )
Policy contract number	ALL CAN LTD
Policy instance	1
Insurance contract or identification number ALL CAN LTD Number of Individuals Covered 65 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $3,289 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $49,921 Commission paid to Insurance Broker USD $3,289 Insurance broker organization code? 3 Insurance broker name PENNSYLVANIA AUTO ASSOC.
UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )
Policy contract number	010128902
Policy instance	7
Insurance contract or identification number 010128902 Number of Individuals Covered 8 Insurance policy start date 2009-04-01 Insurance policy end date 2010-03-31 Welfare Benefit Premiums Paid to Carrier USD $28,685