401k Plan data: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC plan

EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 401k Plan overview

Plan Name	EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC
Plan identification number	501

EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC Benefits

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

401k Sponsoring company profile

CAMBRIA RESIDENTIAL SERVICES INC has sponsored the creation of one or more 401k plans.

Company Name: CAMBRIA RESIDENTIAL SERVICES INC

Employer identification number (EIN): 251405563

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 JAMES J. COOK
501 2016-01-01 JAMES J. COOK
501 2015-01-01 JAMES J. COOK
501 2014-01-01 JAMES J. COOK
501 2013-01-01 JAMES J. COOK
501 2012-01-01 JAMES J. COOK
501 2011-01-01 JAMES J. COOK
501 2010-01-01 JAMES J. COOK
501 2009-01-01 JAMES J. COOK

Plan Statistics for EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC

401k plan membership statisitcs for EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC

Measure Date Value
2023: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2023 401k membership
Total participants, beginning-of-year 2023-01-01 111
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 97
Total of all active and inactive participants 2023-01-01 97
2022: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2022 401k membership
Total participants, beginning-of-year 2022-01-01 127
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 111
Total of all active and inactive participants 2022-01-01 111
2021: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2021 401k membership
Total participants, beginning-of-year 2021-01-01 131
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 127
Total of all active and inactive participants 2021-01-01 127
2020: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2020 401k membership
Total participants, beginning-of-year 2020-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 131
Total of all active and inactive participants 2020-01-01 131
2019: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2019 401k membership
Total participants, beginning-of-year 2019-01-01 114
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 128
Total of all active and inactive participants 2019-01-01 128
2018: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2018 401k membership
Total participants, beginning-of-year 2018-01-01 121
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 114
Total of all active and inactive participants 2018-01-01 114
2017: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2017 401k membership
Total participants, beginning-of-year 2017-01-01 149
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 121
Total of all active and inactive participants 2017-01-01 121
2016: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2016 401k membership
Total participants, beginning-of-year 2016-01-01 168
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 149
Total of all active and inactive participants 2016-01-01 149
2015: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2015 401k membership
Total participants, beginning-of-year 2015-01-01 170
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 168
Total of all active and inactive participants 2015-01-01 168
2014: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2014 401k membership
Total participants, beginning-of-year 2014-01-01 178
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 170
Total of all active and inactive participants 2014-01-01 170
2013: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2013 401k membership
Total participants, beginning-of-year 2013-01-01 186
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 178
Total of all active and inactive participants 2013-01-01 178
2012: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2012 401k membership
Total participants, beginning-of-year 2012-01-01 194
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 186
Total of all active and inactive participants 2012-01-01 186
2011: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2011 401k membership
Total participants, beginning-of-year 2011-01-01 200
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 194
Total of all active and inactive participants 2011-01-01 194
2010: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2010 401k membership
Total participants, beginning-of-year 2010-01-01 212
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 200
Total of all active and inactive participants 2010-01-01 200
2009: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2009 401k membership
Total participants, beginning-of-year 2009-01-01 249
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 212
Total of all active and inactive participants 2009-01-01 212

Measure	Date	Value
2023: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2023 401k membership
Total participants, beginning-of-year	2023-01-01	111
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	97
Total of all active and inactive participants	2023-01-01	97
2022: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2022 401k membership
Total participants, beginning-of-year	2022-01-01	127
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	111
Total of all active and inactive participants	2022-01-01	111
2021: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2021 401k membership
Total participants, beginning-of-year	2021-01-01	131
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	127
Total of all active and inactive participants	2021-01-01	127
2020: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2020 401k membership
Total participants, beginning-of-year	2020-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	131
Total of all active and inactive participants	2020-01-01	131
2019: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2019 401k membership
Total participants, beginning-of-year	2019-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	128
Total of all active and inactive participants	2019-01-01	128
2018: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2018 401k membership
Total participants, beginning-of-year	2018-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	114
Total of all active and inactive participants	2018-01-01	114
2017: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2017 401k membership
Total participants, beginning-of-year	2017-01-01	149
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	121
Total of all active and inactive participants	2017-01-01	121
2016: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2016 401k membership
Total participants, beginning-of-year	2016-01-01	168
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	149
Total of all active and inactive participants	2016-01-01	149
2015: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2015 401k membership
Total participants, beginning-of-year	2015-01-01	170
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	168
Total of all active and inactive participants	2015-01-01	168
2014: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2014 401k membership
Total participants, beginning-of-year	2014-01-01	178
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	170
Total of all active and inactive participants	2014-01-01	170
2013: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2013 401k membership
Total participants, beginning-of-year	2013-01-01	186
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	178
Total of all active and inactive participants	2013-01-01	178
2012: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2012 401k membership
Total participants, beginning-of-year	2012-01-01	194
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	186
Total of all active and inactive participants	2012-01-01	186
2011: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2011 401k membership
Total participants, beginning-of-year	2011-01-01	200
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	194
Total of all active and inactive participants	2011-01-01	194
2010: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2010 401k membership
Total participants, beginning-of-year	2010-01-01	212
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	200
Total of all active and inactive participants	2010-01-01	200
2009: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2009 401k membership
Total participants, beginning-of-year	2009-01-01	249
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	212
Total of all active and inactive participants	2009-01-01	212

Form 5500 Responses for EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC

2023: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan is a collectively bargained plan	Yes
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan is a collectively bargained plan	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan is a collectively bargained plan	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan is a collectively bargained plan	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan is a collectively bargained plan	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan is a collectively bargained plan	Yes
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan is a collectively bargained plan	Yes
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan is a collectively bargained plan	Yes
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan is a collectively bargained plan	Yes
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan is a collectively bargained plan	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan is a collectively bargained plan	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan is a collectively bargained plan	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan is a collectively bargained plan	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan is a collectively bargained plan	Yes
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: EMPLOYEE HEALTH AND WELFARE PLAN OF CAMBRIA RESIDENTIAL SERVICES INC 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan is a collectively bargained plan	Yes
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	91
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,672
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	91
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,208
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $22,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

022124900

Policy instance

Insurance contract or identification number	022124900
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $-663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	88
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $736
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

022124300

Policy instance

Insurance contract or identification number	022124300
Number of Individuals Covered	95
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $31,507
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,165,911
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

022124NC0

Policy instance

Insurance contract or identification number	022124NC0
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $-3
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

022124NN0

Policy instance

Insurance contract or identification number	022124NN0
Number of Individuals Covered	97
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $192
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	100
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,165
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $21,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,165
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	100
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,648
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,648
Insurance broker organization code?	3

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	98
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $700
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $700

UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )

Policy contract number

022124NC0

Policy instance

Insurance contract or identification number	022124NC0
Number of Individuals Covered	0
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21
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

022124NN0

Policy instance

Insurance contract or identification number	022124NN0
Number of Individuals Covered	111
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $174
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $174
Insurance broker organization code?	5

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

Policy contract number

022124900

Policy instance

Insurance contract or identification number	022124900
Number of Individuals Covered	0
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $138
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $138
Insurance broker organization code?	3

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

Policy contract number

022124300

Policy instance

Insurance contract or identification number	022124300
Number of Individuals Covered	111
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $30,085
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $918,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,085
Insurance broker organization code?	5

UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )

Policy contract number

022124NN0

Policy instance

Insurance contract or identification number	022124NN0
Number of Individuals Covered	121
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $149
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $149
Insurance broker organization code?	5

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	106
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,641
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,641
Insurance broker organization code?	3

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	101
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $663
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $663

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

Policy contract number

022124300

Policy instance

Insurance contract or identification number	022124300
Number of Individuals Covered	127
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $30,816
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,021,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,816
Insurance broker organization code?	5

UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )

Policy contract number

022124NC0

Policy instance

Insurance contract or identification number	022124NC0
Number of Individuals Covered	0
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

022124900

Policy instance

Insurance contract or identification number	022124900
Number of Individuals Covered	0
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	106
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,176
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $21,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,176
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	108
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,087
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $20,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,087
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	108
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,572
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,572
Insurance broker organization code?	3

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	103
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $638
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $638
Insurance broker organization code?	5

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

Policy contract number

022124300

Policy instance

Insurance contract or identification number	022124300
Number of Individuals Covered	131
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $36,492
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,071,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,492
Insurance broker organization code?	3

UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )

Policy contract number

022124NC0

Policy instance

Insurance contract or identification number	022124NC0
Number of Individuals Covered	19
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $10
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10
Insurance broker organization code?	3

UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )

Policy contract number

022124NN0

Policy instance

Insurance contract or identification number	022124NN0
Number of Individuals Covered	105
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $126
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,455
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

022124900

Policy instance

Insurance contract or identification number	022124900
Number of Individuals Covered	0
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	128
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $6,298
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $228,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,298
Insurance broker organization code?	5

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	103
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	128
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $20,285
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREFERRED PROVIDER/POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $737,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,285
Insurance broker organization code?	5

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	106
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,474
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,474
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	106
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,961
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $19,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,961
Insurance broker organization code?	3

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	101
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $768
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,361
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $768
Insurance broker organization code?	5

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	99
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	108
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,836
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $18,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,836
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	108
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,311
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,311
Insurance broker organization code?	3

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	114
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $6,902
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $208,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,902
Insurance broker organization code?	5

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	114
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $22,020
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREFERRED PROVIDER/POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $673,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,020
Insurance broker organization code?	5

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	109
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,637
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	109
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	N/A

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	121
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $21,637
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREFERRED PROVIDER/POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $715,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,637
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	121
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $7,578
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $252,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,578
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	107
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	116
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,239
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,239
Insurance broker organization code?	3
Insurance broker name	BABB INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	116
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,778
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $17,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,778
Insurance broker organization code?	3
Insurance broker name	BABB INC

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	108
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	N/A

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	168
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $22,370
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREFERRED PROVIDER/POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $744,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,370
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	168
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $6,517
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $220,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,517
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	117
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,160
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,160
Insurance broker organization code?	3
Insurance broker name	BABB INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	118
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,712
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $17,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,712
Insurance broker organization code?	3
Insurance broker name	BABB INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	105
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	105
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	N/A

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	113
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,155
Total amount of fees paid to insurance company	USD $458
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,155
Amount paid for insurance broker fees	458
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BABB INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	107
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	170
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $23,557
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREFERRED PROVIDER/POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $781,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,557
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	170
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $5,532
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $185,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,532
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	114
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,710
Total amount of fees paid to insurance company	USD $540
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $17,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,710
Amount paid for insurance broker fees	540
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BABB INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	178
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $23,681
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREFERRED PROVIDER/POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $862,337
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,681
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	178
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $4,801
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $174,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,801
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	111
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	N/A

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	111
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,661
Total amount of fees paid to insurance company	USD $377
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $16,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,661
Amount paid for insurance broker fees	377
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BABB INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	110
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,115
Total amount of fees paid to insurance company	USD $319
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,115
Amount paid for insurance broker fees	319
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BABB INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	110
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	186
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $24,177
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREFERRED PROVIDER/POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $801,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,177
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	115
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	114
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,825
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,825
Insurance broker organization code?	3
Insurance broker name	BABB INC

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	113
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	N/A

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	186
Insurance policy start date	2011-11-01
Insurance policy end date	2012-10-31
Total amount of commissions paid to insurance broker	USD $4,877
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $162,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,877
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	115
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,497
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $16,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,497
Insurance broker organization code?	3
Insurance broker name	BABB INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	194
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $24,858
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREFERRED PROVIDER/POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $827,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	194
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $5,039
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $167,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	114
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	120
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,113
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $17,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	119
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,522
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	114
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

260123-000

Policy instance

Insurance contract or identification number	260123-000
Number of Individuals Covered	120
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	N/A

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	200
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $22,154
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	PREFERRED PROVIDER/POINT OF SERVICE
Welfare Benefit Premiums Paid to Carrier	USD $788,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,154
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	200
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $5,479
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $199,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,479
Insurance broker organization code?	5
Insurance broker name	THE HDH GROUP INC

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

Policy contract number

4249700

Policy instance

Insurance contract or identification number	4249700
Number of Individuals Covered	119
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	125
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,709
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $17,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,709
Insurance broker organization code?	3
Insurance broker name	BABB INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000586K

Policy instance

Insurance contract or identification number	G000586K
Number of Individuals Covered	124
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,183
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,183
Insurance broker organization code?	3
Insurance broker name	BABB INC

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Company Name:	CAMBRIA RESIDENTIAL SERVICES INC
Employer identification number (EIN):	251405563
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities