401k Plan data: ACHIEVA WELFARE BENEFIT PLAN plan

ACHIEVA WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	ACHIEVA WELFARE BENEFIT PLAN
Plan identification number	501

ACHIEVA WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

ACHIEVA has sponsored the creation of one or more 401k plans.

Company Name: ACHIEVA

Employer identification number (EIN): 251505216

NAIC Classification: 624100
NAIC Description: Individual and Family Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ACHIEVA WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 MARSHA TURNER 2024-09-20
501 2022-01-01 MARSHA TURNER 2023-10-11
501 2021-01-01 ROMA CONSTANTINE 2022-10-11
501 2020-01-01 ROMA CONSTANTINE 2021-08-04
501 2019-01-01 ROMA CONSTANTINE 2020-08-28
501 2018-01-01 ROMA CONSTANTINE 2019-09-18
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 DEBRA F. LYNCH
501 2011-01-01 DEBRA F. LYNCH
501 2010-01-01 DEBRA F. LYNCH
501 2009-01-01 DEBRA F. LYNCH
501 2009-01-01 DEBRA F. LYNCH

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2023-01-01	MARSHA TURNER	2024-09-20
501	2022-01-01	MARSHA TURNER	2023-10-11
501	2021-01-01	ROMA CONSTANTINE	2022-10-11
501	2020-01-01	ROMA CONSTANTINE	2021-08-04
501	2019-01-01	ROMA CONSTANTINE	2020-08-28
501	2018-01-01	ROMA CONSTANTINE	2019-09-18
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	DEBRA F. LYNCH
501	2011-01-01	DEBRA F. LYNCH
501	2010-01-01	DEBRA F. LYNCH
501	2009-01-01	DEBRA F. LYNCH
501	2009-01-01	DEBRA F. LYNCH

Plan Statistics for ACHIEVA WELFARE BENEFIT PLAN

401k plan membership statisitcs for ACHIEVA WELFARE BENEFIT PLAN

Measure Date Value
2023: ACHIEVA WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 345
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 331
Number of retired or separated participants receiving benefits 2023-01-01 1
Number of other retired or separated participants entitled to future benefits 2023-01-01 8
Total of all active and inactive participants 2023-01-01 340
2022: ACHIEVA WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 355
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 344
Number of retired or separated participants receiving benefits 2022-01-01 1
Total of all active and inactive participants 2022-01-01 345
2021: ACHIEVA WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 402
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 370
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 2021-01-01 371
2020: ACHIEVA WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 419
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 402
Number of retired or separated participants receiving benefits 2020-01-01 5
Total of all active and inactive participants 2020-01-01 407
2019: ACHIEVA WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 473
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 419
Number of retired or separated participants receiving benefits 2019-01-01 4
Total of all active and inactive participants 2019-01-01 423
2018: ACHIEVA WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 477
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 468
Number of retired or separated participants receiving benefits 2018-01-01 6
Total of all active and inactive participants 2018-01-01 474
2017: ACHIEVA WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 463
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 477
Number of retired or separated participants receiving benefits 2017-01-01 5
Total of all active and inactive participants 2017-01-01 482
2016: ACHIEVA WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 450
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 455
Number of retired or separated participants receiving benefits 2016-01-01 8
Total of all active and inactive participants 2016-01-01 463
2015: ACHIEVA WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 469
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 442
Number of other retired or separated participants entitled to future benefits 2015-01-01 8
Total of all active and inactive participants 2015-01-01 450
2014: ACHIEVA WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 597
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 461
Number of retired or separated participants receiving benefits 2014-01-01 7
Total of all active and inactive participants 2014-01-01 468
2013: ACHIEVA WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 632
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 590
Number of retired or separated participants receiving benefits 2013-01-01 7
Total of all active and inactive participants 2013-01-01 597
2012: ACHIEVA WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 518
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 615
Number of retired or separated participants receiving benefits 2012-01-01 17
Total of all active and inactive participants 2012-01-01 632
2011: ACHIEVA WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 500
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 505
Number of retired or separated participants receiving benefits 2011-01-01 13
Total of all active and inactive participants 2011-01-01 518
2010: ACHIEVA WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 375
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 529
Number of retired or separated participants receiving benefits 2010-01-01 11
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 540
2009: ACHIEVA WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 381
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 371
Number of retired or separated participants receiving benefits 2009-01-01 4
Total of all active and inactive participants 2009-01-01 375

Measure	Date	Value
2023: ACHIEVA WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	345
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	331
Number of retired or separated participants receiving benefits	2023-01-01	1
Number of other retired or separated participants entitled to future benefits	2023-01-01	8
Total of all active and inactive participants	2023-01-01	340
2022: ACHIEVA WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	355
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	344
Number of retired or separated participants receiving benefits	2022-01-01	1
Total of all active and inactive participants	2022-01-01	345
2021: ACHIEVA WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	402
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	370
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	371
2020: ACHIEVA WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	419
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	402
Number of retired or separated participants receiving benefits	2020-01-01	5
Total of all active and inactive participants	2020-01-01	407
2019: ACHIEVA WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	473
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	419
Number of retired or separated participants receiving benefits	2019-01-01	4
Total of all active and inactive participants	2019-01-01	423
2018: ACHIEVA WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	477
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	468
Number of retired or separated participants receiving benefits	2018-01-01	6
Total of all active and inactive participants	2018-01-01	474
2017: ACHIEVA WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	463
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	477
Number of retired or separated participants receiving benefits	2017-01-01	5
Total of all active and inactive participants	2017-01-01	482
2016: ACHIEVA WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	450
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	455
Number of retired or separated participants receiving benefits	2016-01-01	8
Total of all active and inactive participants	2016-01-01	463
2015: ACHIEVA WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	469
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	442
Number of other retired or separated participants entitled to future benefits	2015-01-01	8
Total of all active and inactive participants	2015-01-01	450
2014: ACHIEVA WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	597
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	461
Number of retired or separated participants receiving benefits	2014-01-01	7
Total of all active and inactive participants	2014-01-01	468
2013: ACHIEVA WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	632
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	590
Number of retired or separated participants receiving benefits	2013-01-01	7
Total of all active and inactive participants	2013-01-01	597
2012: ACHIEVA WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	518
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	615
Number of retired or separated participants receiving benefits	2012-01-01	17
Total of all active and inactive participants	2012-01-01	632
2011: ACHIEVA WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	500
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	505
Number of retired or separated participants receiving benefits	2011-01-01	13
Total of all active and inactive participants	2011-01-01	518
2010: ACHIEVA WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	375
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	529
Number of retired or separated participants receiving benefits	2010-01-01	11
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	540
2009: ACHIEVA WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	381
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	371
Number of retired or separated participants receiving benefits	2009-01-01	4
Total of all active and inactive participants	2009-01-01	375

Form 5500 Responses for ACHIEVA WELFARE BENEFIT PLAN

2023: ACHIEVA WELFARE BENEFIT PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: ACHIEVA WELFARE BENEFIT 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: ACHIEVA WELFARE BENEFIT 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: ACHIEVA WELFARE BENEFIT 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: ACHIEVA WELFARE BENEFIT 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: ACHIEVA WELFARE BENEFIT 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: ACHIEVA WELFARE BENEFIT 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: ACHIEVA WELFARE BENEFIT 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: ACHIEVA WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: ACHIEVA WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: ACHIEVA WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: ACHIEVA WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: ACHIEVA WELFARE BENEFIT 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
2010: ACHIEVA WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: ACHIEVA WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

120878

Policy instance

Insurance contract or identification number	120878
Number of Individuals Covered	49
Insurance policy start date	2023-01-01
Insurance policy end date	2024-01-01
Total amount of commissions paid to insurance broker	USD $3,622
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $24,149
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	338
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981 0001

Policy instance

Insurance contract or identification number	093981 0001
Number of Individuals Covered	36
Insurance policy start date	2023-01-01
Insurance policy end date	2024-01-01
Total amount of commissions paid to insurance broker	USD $1,840
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,268
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

000245801

Policy instance

Insurance contract or identification number	000245801
Number of Individuals Covered	525
Insurance policy start date	2023-07-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $54,045
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $1,858,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

241242

Policy instance

Insurance contract or identification number	241242
Number of Individuals Covered	416
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $16,194
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $170,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008529658

Policy instance

Insurance contract or identification number	0008529658
Number of Individuals Covered	133
Insurance policy start date	2023-01-01
Insurance policy end date	2024-01-01
Total amount of commissions paid to insurance broker	USD $773
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,699
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

000245NC0

Policy instance

Insurance contract or identification number	000245NC0
Number of Individuals Covered	1
Insurance policy start date	2023-07-01
Insurance policy end date	2023-12-31
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $280
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

000245904

Policy instance

Insurance contract or identification number	000245904
Number of Individuals Covered	1
Insurance policy start date	2023-07-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $247
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $6,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

939949

Policy instance

Insurance contract or identification number	939949
Number of Individuals Covered	312
Insurance policy start date	2023-01-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $3,781
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,256
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

000245NN0

Policy instance

Insurance contract or identification number	000245NN0
Number of Individuals Covered	594
Insurance policy start date	2023-07-01
Insurance policy end date	2023-12-31
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,421
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

000245904

Policy instance

Insurance contract or identification number	000245904
Number of Individuals Covered	1
Insurance policy start date	2023-01-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $81
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $4,778
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

000245801

Policy instance

Insurance contract or identification number	000245801
Number of Individuals Covered	540
Insurance policy start date	2023-01-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $36,704
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $2,190,318
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

000245302

Policy instance

Insurance contract or identification number	000245302
Number of Individuals Covered	0
Insurance policy start date	2023-07-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $66
Total amount of fees paid to insurance company	USD $0
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

000245302

Policy instance

Insurance contract or identification number	000245302
Number of Individuals Covered	2
Insurance policy start date	2023-01-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $331
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $20,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981 0800

Policy instance

Insurance contract or identification number	093981 0800
Number of Individuals Covered	1
Insurance policy start date	2023-01-01
Insurance policy end date	2024-01-01
Total amount of commissions paid to insurance broker	USD $1,834
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	329
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981 0100

Policy instance

Insurance contract or identification number	093981 0100
Number of Individuals Covered	42
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $2,116
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,116
Insurance broker organization code?	3

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

Policy contract number

000245801

Policy instance

Insurance contract or identification number	000245801
Number of Individuals Covered	497
Insurance policy start date	2022-07-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $30,199
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,815,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,199
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

241242

Policy instance

Insurance contract or identification number	241242
Number of Individuals Covered	437
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $15,361
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $165,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,758
Insurance broker organization code?	3

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

Policy contract number

000245301

Policy instance

Insurance contract or identification number	000245301
Number of Individuals Covered	542
Insurance policy start date	2022-01-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $37,367
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,860,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,367
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008529658

Policy instance

Insurance contract or identification number	0008529658
Number of Individuals Covered	164
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $1,340
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $617
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

120878

Policy instance

Insurance contract or identification number	120878
Number of Individuals Covered	63
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $4,404
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $26,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,404
Insurance broker organization code?	3

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

Policy contract number

000245904

Policy instance

Insurance contract or identification number	000245904
Number of Individuals Covered	1
Insurance policy start date	2022-07-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $67
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,085
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

939949

Policy instance

Insurance contract or identification number	939949
Number of Individuals Covered	362
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,930
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $152,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,930
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981 0800

Policy instance

Insurance contract or identification number	093981 0800
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $1,444
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,625
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

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

Policy contract number

000245300

Policy instance

Insurance contract or identification number	000245300
Number of Individuals Covered	260
Insurance policy start date	2021-01-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $18,523
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $664,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,523
Insurance broker organization code?	3

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

Policy contract number

000245902

Policy instance

Insurance contract or identification number	000245902
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $82
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $82
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981

Policy instance

Insurance contract or identification number	29183
Number of Individuals Covered	147
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,061
Total amount of fees paid to insurance company	USD $649
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS AND CANCER
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $46,421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,061
Insurance broker organization code?	3
Amount paid for insurance broker fees	649
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	381
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

241242

Policy instance

Insurance contract or identification number	241242
Number of Individuals Covered	515
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $11,211
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $165,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,168
Insurance broker organization code?	3

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

Policy contract number

000245301

Policy instance

Insurance contract or identification number	000245301
Number of Individuals Covered	591
Insurance policy start date	2021-07-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $30,342
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,505,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,342
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008529658

Policy instance

Insurance contract or identification number	0008529658
Number of Individuals Covered	189
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $2,388
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,664
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

120878

Policy instance

Insurance contract or identification number	120878
Number of Individuals Covered	68
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $4,622
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $31,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,622
Insurance broker organization code?	3

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

Policy contract number

000245903

Policy instance

Insurance contract or identification number	000245903
Number of Individuals Covered	1
Insurance policy start date	2021-07-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $295
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $295
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

939949

Policy instance

Insurance contract or identification number	939949
Number of Individuals Covered	404
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,078
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $176,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,078
Insurance broker organization code?	3

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

Policy contract number

000245300

Policy instance

Insurance contract or identification number	000245300
Number of Individuals Covered	270
Insurance policy start date	2020-07-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $16,148
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $823,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,148
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

241242

Policy instance

Insurance contract or identification number	241242
Number of Individuals Covered	512
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,996
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $182,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,996
Insurance broker organization code?	3

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

Policy contract number

000245300

Policy instance

Insurance contract or identification number	000245300
Number of Individuals Covered	268
Insurance policy start date	2020-01-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $16,254
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $947,120
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,254
Insurance broker organization code?	3

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

Policy contract number

000245902

Policy instance

Insurance contract or identification number	000245902
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $201
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $201
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981 0001

Policy instance

Insurance contract or identification number	093981 0001
Number of Individuals Covered	56
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $2,503
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,503
Insurance broker organization code?	3

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

Policy contract number

252302-000

Policy instance

Insurance contract or identification number	252302-000
Number of Individuals Covered	667
Insurance policy start date	2020-01-01
Insurance policy end date	2020-06-30
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	421
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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
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

000245902

Policy instance

Insurance contract or identification number	000245902
Number of Individuals Covered	1
Insurance policy start date	2020-07-01
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 $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,537
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 OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

000245301

Policy instance

Insurance contract or identification number	000245301
Number of Individuals Covered	374
Insurance policy start date	2020-07-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $22,619
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,150,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,619
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

939949

Policy instance

Insurance contract or identification number	939949
Number of Individuals Covered	414
Insurance policy start date	2020-07-01
Insurance policy end date	2020-12-31
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 $94,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981 0800

Policy instance

Insurance contract or identification number	093981 0800
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $1,667
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,667
Insurance broker organization code?	3

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

Policy contract number

000245903

Policy instance

Insurance contract or identification number	000245903
Number of Individuals Covered	2
Insurance policy start date	2020-01-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $155
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $155

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

Policy contract number

000245903

Policy instance

Insurance contract or identification number	000245903
Number of Individuals Covered	1
Insurance policy start date	2020-07-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $47
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47
Insurance broker organization code?	3

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

Policy contract number

000245301

Policy instance

Insurance contract or identification number	000245301
Number of Individuals Covered	375
Insurance policy start date	2020-01-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $21,539
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,285,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,539
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

120878

Policy instance

Insurance contract or identification number	120878
Number of Individuals Covered	75
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $5,543
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,543
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008529658

Policy instance

Insurance contract or identification number	0008529658
Number of Individuals Covered	196
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $3,308
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,432
Insurance broker organization code?	3

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

Policy contract number

000245301

Policy instance

Insurance contract or identification number	000245301
Number of Individuals Covered	289
Insurance policy start date	2019-01-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $18,315
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $791,193
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,315
Insurance broker organization code?	3

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

Policy contract number

000245903

Policy instance

Insurance contract or identification number	000245903
Number of Individuals Covered	3
Insurance policy start date	2019-07-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $176
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $176
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008529658

Policy instance

Insurance contract or identification number	0008529658
Number of Individuals Covered	213
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $2,905
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,148
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
Insurance broker organization code?	3

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

Policy contract number

000245301

Policy instance

Insurance contract or identification number	000245301
Number of Individuals Covered	374
Insurance policy start date	2019-07-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $17,961
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,086,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,961
Insurance broker organization code?	3

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

Policy contract number

000245902

Policy instance

Insurance contract or identification number	000245902
Number of Individuals Covered	4
Insurance policy start date	2019-07-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $55
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,449
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55
Insurance broker organization code?	3

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

Policy contract number

000245300

Policy instance

Insurance contract or identification number	000245300
Number of Individuals Covered	292
Insurance policy start date	2019-07-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $14,651
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $876,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,651
Insurance broker organization code?	3

UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )

Policy contract number

251025-000

Policy instance

Insurance contract or identification number	251025-000
Number of Individuals Covered	120
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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 $16,651
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

252302-000

Policy instance

Insurance contract or identification number	252302-000
Number of Individuals Covered	744
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

241242

Policy instance

Insurance contract or identification number	241242
Number of Individuals Covered	543
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,429
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $182,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,429
Insurance broker organization code?	3

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

Policy contract number

000245300

Policy instance

Insurance contract or identification number	000245300
Number of Individuals Covered	435
Insurance policy start date	2019-01-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $29,889
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,295,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,889
Insurance broker organization code?	3

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

Policy contract number

000245902

Policy instance

Insurance contract or identification number	000245902
Number of Individuals Covered	7
Insurance policy start date	2019-01-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $340
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,553
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $340
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981

Policy instance

Insurance contract or identification number	093981
Number of Individuals Covered	286
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $4,080
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,080
Insurance broker organization code?	3

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	451
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

120878

Policy instance

Insurance contract or identification number	120878
Number of Individuals Covered	77
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $5,574
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,574
Insurance broker organization code?	3

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

Policy contract number

252302-001

Policy instance

Insurance contract or identification number	252302-001
Number of Individuals Covered	762
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008529658

Policy instance

Insurance contract or identification number	0008529658
Number of Individuals Covered	221
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $2,665
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,916
Insurance broker organization code?	3

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

Policy contract number

000245301

Policy instance

Insurance contract or identification number	000245301
Number of Individuals Covered	286
Insurance policy start date	2018-07-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $12,623
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $771,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,623
Insurance broker organization code?	3

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

Policy contract number

000245902

Policy instance

Insurance contract or identification number	000245902
Number of Individuals Covered	10
Insurance policy start date	2018-07-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $440
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $440
Insurance broker organization code?	3

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

Policy contract number

000245300

Policy instance

Insurance contract or identification number	000245300
Number of Individuals Covered	449
Insurance policy start date	2018-07-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $28,725
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $986,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,725
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

241242

Policy instance

Insurance contract or identification number	241242
Number of Individuals Covered	566
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,956
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $180,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,956
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981

Policy instance

Insurance contract or identification number	093981
Number of Individuals Covered	73
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $4,213
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,213
Insurance broker organization code?	3

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	501
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )

Policy contract number

251025-000

Policy instance

Insurance contract or identification number	251025-000
Number of Individuals Covered	118
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
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 $17,260
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

000245902

Policy instance

Insurance contract or identification number	000245902
Number of Individuals Covered	11
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $323
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $323
Insurance broker organization code?	3

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

Policy contract number

000245300

Policy instance

Insurance contract or identification number	000245300
Number of Individuals Covered	721
Insurance policy start date	2018-01-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $41,536
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,422,144
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,536
Insurance broker organization code?	3

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

Policy contract number

000245902

Policy instance

Insurance contract or identification number	000245902
Number of Individuals Covered	5
Insurance policy start date	2017-07-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $203
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $203
Insurance broker organization code?	3
Insurance broker name	SEUBERT & ASSOCIATES

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

Policy contract number

252302-000

Policy instance

Insurance contract or identification number	252302-000
Number of Individuals Covered	726
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )

Policy contract number

251025-000

Policy instance

Insurance contract or identification number	251025-000
Number of Individuals Covered	141
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	502
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

120878

Policy instance

Insurance contract or identification number	120878
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
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

000245902

Policy instance

Insurance contract or identification number	000245902
Number of Individuals Covered	2
Insurance policy start date	2017-01-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $53
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53
Insurance broker organization code?	3
Insurance broker name	SEUBERT & ASSOCIATES

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

Policy contract number

000245300

Policy instance

Insurance contract or identification number	000245300
Number of Individuals Covered	681
Insurance policy start date	2017-01-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $33,050
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,342,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,050
Insurance broker organization code?	3
Insurance broker name	SEUBERT & ASSOCIATES

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

241242

Policy instance

Insurance contract or identification number	241242
Number of Individuals Covered	584
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $8,608
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $176,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,454
Insurance broker organization code?	3
Insurance broker name	4 I BENEFITS GROUP LLC

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

Policy contract number

000245300

Policy instance

Insurance contract or identification number	000245300
Number of Individuals Covered	741
Insurance policy start date	2017-07-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $41,398
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,776,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,398
Insurance broker organization code?	3
Insurance broker name	SEUBERT & ASSOCIATES

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

Policy contract number

000245300

Policy instance

Insurance contract or identification number	000245300
Number of Individuals Covered	667
Insurance policy start date	2015-07-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $26,379
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,906,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,379
Insurance broker name	SEUBERT & ASSOCIATES INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

120878

Policy instance

Insurance contract or identification number	120878
Number of Individuals Covered	126
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $5,970
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $36,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,970
Insurance broker organization code?	3
Insurance broker name	MARTHINSEN & SALVITTI INSURANCE

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

241242

Policy instance

Insurance contract or identification number	241242
Number of Individuals Covered	564
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,198
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $81,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,198
Insurance broker organization code?	3
Insurance broker name	ZARAS GEORGE

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

Policy contract number

000245902

Policy instance

Insurance contract or identification number	000245902
Number of Individuals Covered	8
Insurance policy start date	2015-07-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $393
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $393
Insurance broker organization code?	3
Insurance broker name	SEUBERT & ASSOCIATES INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981

Policy instance

Insurance contract or identification number	093981
Number of Individuals Covered	87
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $2,971
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,971
Insurance broker organization code?	3
Insurance broker name	MARTHINSEN & SALVITTI INSURANCE

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	474
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )

Policy contract number

251025-000

Policy instance

Insurance contract or identification number	251025-000
Number of Individuals Covered	183
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,029
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

252302-000

Policy instance

Insurance contract or identification number	252302-000
Number of Individuals Covered	689
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIGHMARK CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 35599 )

Policy contract number

404716 0010

Policy instance

Insurance contract or identification number	404716 0010
Number of Individuals Covered	471
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $384,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	SEUBERT & ASSOCIATES INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

0398117

Policy instance

Insurance contract or identification number	0398117
Number of Individuals Covered	161
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $3,301
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $25,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,301
Insurance broker organization code?	3
Insurance broker name	GEORGE A. ZARAS

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

Policy contract number

252302-000

Policy instance

Insurance contract or identification number	252302-000
Number of Individuals Covered	683
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,683
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,683
Insurance broker organization code?	3
Insurance broker name	SEUBERT & ASSOCIATES INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

294806

Policy instance

Insurance contract or identification number	294806
Number of Individuals Covered	445
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $7,718
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $95,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,718
Insurance broker organization code?	3
Insurance broker name	GEORGE A. ZARAS

UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )

Policy contract number

251025-000

Policy instance

Insurance contract or identification number	251025-000
Number of Individuals Covered	189
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $352
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 $22,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $352
Insurance broker organization code?	3
Insurance broker name	SEUBERT & ASSOCIATES INC.

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	486
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $470
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $470
Insurance broker organization code?	3
Insurance broker name	SEUBERT & ASSOCIATES INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

294806

Policy instance

Insurance contract or identification number	294806
Number of Individuals Covered	430
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $7,574
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $94,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,574
Insurance broker organization code?	3
Insurance broker name	GEORGE A. ZARAS

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

Policy contract number

5924930000

Policy instance

Insurance contract or identification number	5924930000
Number of Individuals Covered	0
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $39,327
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,310,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,197
Insurance broker organization code?	3
Insurance broker name	NEISHLOSS - MARTHINSON & SALVITTI

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK600089

Policy instance

Insurance contract or identification number	SOK600089
Number of Individuals Covered	165
Insurance policy start date	2013-02-01
Insurance policy end date	2014-02-01
Total amount of commissions paid to insurance broker	USD $35
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35
Insurance broker organization code?	7
Insurance broker name	WELLS FARGO INSURANCE SERVICE

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD600240

Policy instance

Insurance contract or identification number	SGD600240
Number of Individuals Covered	165
Insurance policy start date	2013-02-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $256
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 $1,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $256
Insurance broker organization code?	7
Insurance broker name	WELLS FARGO INSURANCE SERVICE

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM600330

Policy instance

Insurance contract or identification number	SGM600330
Number of Individuals Covered	165
Insurance policy start date	2013-02-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $186
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
Welfare Benefit Premiums Paid to Carrier	USD $1,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $186
Insurance broker organization code?	7
Insurance broker name	WELLS FARGO INSURANCE SERVICE

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

Policy contract number

5924940000

Policy instance

Insurance contract or identification number	5924940000
Number of Individuals Covered	0
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $8,145
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $271,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,414
Insurance broker organization code?	3
Insurance broker name	NEISHLOSS - MARTHINSON & SALVITTI

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	478
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,239
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,239
Insurance broker organization code?	3
Insurance broker name	SEUBERT & ASSOCIATES INC.

HIGHMARK CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 35599 )

Policy contract number

404716 0010

Policy instance

Insurance contract or identification number	404716 0010
Number of Individuals Covered	451
Insurance policy start date	2013-07-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $125,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )

Policy contract number

251025-000

Policy instance

Insurance contract or identification number	251025-000
Number of Individuals Covered	231
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $777
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 $25,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $641
Insurance broker organization code?	3
Insurance broker name	MARTHINSEN & SALVITI INS. GROUP

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

Policy contract number

252302-000

Policy instance

Insurance contract or identification number	252302-000
Number of Individuals Covered	675
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,259
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,386
Insurance broker organization code?	3
Insurance broker name	MARTHINSEN & SALVITI INS. GROUP

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981

Policy instance

Insurance contract or identification number	093981
Number of Individuals Covered	267
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $4,511
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
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $42,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,511
Insurance broker organization code?	3
Insurance broker name	MARTHINSON & SALVITTI

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

0398117

Policy instance

Insurance contract or identification number	0398117
Number of Individuals Covered	165
Insurance policy start date	2013-03-01
Insurance policy end date	2013-07-01
Total amount of commissions paid to insurance broker	USD $1,631
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $6,570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,631
Insurance broker organization code?	3
Insurance broker name	GEORGE A. ZARAS

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

Policy contract number

252302-000

Policy instance

Insurance contract or identification number	252302-000
Number of Individuals Covered	680
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,266
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,266
Insurance broker organization code?	3
Insurance broker name	MARTHINSEN & SALVITI INS. GROUP

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981

Policy instance

Insurance contract or identification number	093981
Number of Individuals Covered	271
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $3,143
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 $37,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,143
Insurance broker organization code?	3
Insurance broker name	MARTHINSEN & SALVITTI INS. GROUP

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	501
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $809
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $809
Insurance broker organization code?	3
Insurance broker name	MATHINSEN & SALVITTI INSURANCE GROU

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD600240

Policy instance

Insurance contract or identification number	SGD600240
Number of Individuals Covered	169
Insurance policy start date	2012-02-01
Insurance policy end date	2013-02-01
Total amount of commissions paid to insurance broker	USD $1,496
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 $9,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,496
Insurance broker organization code?	7
Insurance broker name	WELLS FARGO INSURANCE SERVICE

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

294806

Policy instance

Insurance contract or identification number	294806
Number of Individuals Covered	433
Insurance policy start date	2012-07-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $5,667
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $51,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,667
Insurance broker name	GEORGE A. ZARAS

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

048679700

Policy instance

Insurance contract or identification number	048679700
Number of Individuals Covered	465
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $55,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK600089

Policy instance

Insurance contract or identification number	SOK600089
Number of Individuals Covered	169
Insurance policy start date	2012-02-01
Insurance policy end date	2013-02-01
Total amount of commissions paid to insurance broker	USD $209
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $209
Insurance broker organization code?	7
Insurance broker name	WELLS FARGO INSURANCE SERVICE

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

Policy contract number

5924930000

Policy instance

Insurance contract or identification number	5924930000
Number of Individuals Covered	653
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $78,753
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,625,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $78,753
Insurance broker organization code?	3
Insurance broker name	NEISHLOSS - MARTHINSON & SALVITTI

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

Policy contract number

5924940000

Policy instance

Insurance contract or identification number	5924940000
Number of Individuals Covered	141
Insurance policy start date	2012-07-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $17,025
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $567,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,025
Insurance broker organization code?	3
Insurance broker name	NEISHLOSS - MARTHINSON & SALVITTI

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

120878

Policy instance

Insurance contract or identification number	120878
Number of Individuals Covered	103
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $3,858
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $28,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,858
Insurance broker name	MARTHINSEN & SALVITTI INS. GROUP

UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )

Policy contract number

251025-000

Policy instance

Insurance contract or identification number	251025-000
Number of Individuals Covered	243
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $899
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 $30,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $899
Insurance broker organization code?	3
Insurance broker name	MARTHINSEN & SALVITI INS. GROUP

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM600330

Policy instance

Insurance contract or identification number	SGM600330
Number of Individuals Covered	169
Insurance policy start date	2012-02-01
Insurance policy end date	2013-02-01
Total amount of commissions paid to insurance broker	USD $1,104
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
Welfare Benefit Premiums Paid to Carrier	USD $8,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,104
Insurance broker organization code?	7
Insurance broker name	WELLS FARGO INSURANCE SERVICE

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

Policy contract number

5924930000

Policy instance

Insurance contract or identification number	5924930000
Number of Individuals Covered	697
Insurance policy start date	2011-07-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $40,056
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,335,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )

Policy contract number

251025-000

Policy instance

Insurance contract or identification number	251025-000
Number of Individuals Covered	244
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,036
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 $33,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

048679700

Policy instance

Insurance contract or identification number	048679700
Number of Individuals Covered	462
Insurance policy start date	2010-11-01
Insurance policy end date	2011-11-01
Total amount of commissions paid to insurance broker	USD $6,502
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $114,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5924940000

Policy instance

Insurance contract or identification number	5924940000
Number of Individuals Covered	144
Insurance policy start date	2011-07-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $8,343
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $278,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981

Policy instance

Insurance contract or identification number	093981
Number of Individuals Covered	231
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,698
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 $36,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1457-0001

Policy instance

Insurance contract or identification number	1457-0001
Number of Individuals Covered	148
Insurance policy start date	2011-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $338
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	370
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $971
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

109734

Policy instance

Insurance contract or identification number	109734
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $48,751
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,765,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD600240

Policy instance

Insurance contract or identification number	SGD600240
Number of Individuals Covered	158
Insurance policy start date	2011-02-01
Insurance policy end date	2012-02-01
Total amount of commissions paid to insurance broker	USD $1,688
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 $9,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM600330

Policy instance

Insurance contract or identification number	SGM600330
Number of Individuals Covered	158
Insurance policy start date	2011-02-01
Insurance policy end date	2012-02-01
Total amount of commissions paid to insurance broker	USD $1,165
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
Welfare Benefit Premiums Paid to Carrier	USD $9,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK600089

Policy instance

Insurance contract or identification number	SOK600089
Number of Individuals Covered	158
Insurance policy start date	2011-02-01
Insurance policy end date	2012-02-01
Total amount of commissions paid to insurance broker	USD $286
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

010704300

Policy instance

Insurance contract or identification number	010704300
Number of Individuals Covered	112
Insurance policy start date	2011-01-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $6,466
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 $258,659
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

252302-000

Policy instance

Insurance contract or identification number	252302-000
Number of Individuals Covered	681
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,512
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM600330

Policy instance

Insurance contract or identification number	SGM600330
Number of Individuals Covered	179
Insurance policy start date	2010-02-01
Insurance policy end date	2011-02-01
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
Welfare Benefit Premiums Paid to Carrier	USD $9,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

5OK600089

Policy instance

Insurance contract or identification number	5OK600089
Number of Individuals Covered	179
Insurance policy start date	2010-02-01
Insurance policy end date	2011-02-01
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
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $1,440
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

252302-000

Policy instance

Insurance contract or identification number	252302-000
Number of Individuals Covered	712
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,609
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )

Policy contract number

251025-000

Policy instance

Insurance contract or identification number	251025-000
Number of Individuals Covered	264
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $923
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 $33,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

048679700

Policy instance

Insurance contract or identification number	048679700
Number of Individuals Covered	475
Insurance policy start date	2009-11-01
Insurance policy end date	2010-11-01
Total amount of commissions paid to insurance broker	USD $6,392
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $101,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

093981

Policy instance

Insurance contract or identification number	093981
Number of Individuals Covered	212
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,853
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 $38,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1457

Policy instance

Insurance contract or identification number	1457
Number of Individuals Covered	371
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $688
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1457-0001

Policy instance

Insurance contract or identification number	1457-0001
Number of Individuals Covered	170
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $255
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

109734

Policy instance

Insurance contract or identification number	109734
Number of Individuals Covered	685
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $92,389
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,342,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95216 )

Policy contract number

010704800

Policy instance

Insurance contract or identification number	010704800
Number of Individuals Covered	61
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $8,374
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
Other welfare benefits provided	EPO PRODUCT
Welfare Benefit Premiums Paid to Carrier	USD $318,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95216 )

Policy contract number

010704900

Policy instance

Insurance contract or identification number	010704900
Number of Individuals Covered	3
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $719
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 $24,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95216 )

Policy contract number

010704902

Policy instance

Insurance contract or identification number	010704902
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $125
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
Other welfare benefits provided	EPO PRODUCT
Welfare Benefit Premiums Paid to Carrier	USD $5,018
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD600240

Policy instance

Insurance contract or identification number	SGD600240
Number of Individuals Covered	179
Insurance policy start date	2010-02-01
Insurance policy end date	2011-02-01
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95216 )

Policy contract number

010704300

Policy instance

Insurance contract or identification number	010704300
Number of Individuals Covered	97
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $14,874
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 $508,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	ACHIEVA
Employer identification number (EIN):	251505216
NAIC Classification:	624100
NAIC Description:	Individual and Family Services