401k Plan data: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN plan

KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN
Plan identification number	501

KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

KRATZENBERG & ASSOCIATES INC. has sponsored the creation of one or more 401k plans.

Company Name: KRATZENBERG & ASSOCIATES INC.

Employer identification number (EIN): 251780727

NAIC Classification: 541219
NAIC Description: Other Accounting Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-12-01
501 2021-12-01
501 2020-12-01
501 2019-12-01

Plan Statistics for KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN

401k plan membership statisitcs for KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN

Measure Date Value
2022: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-12-01 177
Total number of active participants reported on line 7a of the Form 5500 2022-12-01 179
Total of all active and inactive participants 2022-12-01 179
Total participants 2022-12-01 179
2021: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-12-01 172
Total number of active participants reported on line 7a of the Form 5500 2021-12-01 177
Total of all active and inactive participants 2021-12-01 177
Total participants 2021-12-01 177
2020: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-12-01 174
Total number of active participants reported on line 7a of the Form 5500 2020-12-01 172
Total of all active and inactive participants 2020-12-01 172
Total participants 2020-12-01 172
2019: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-12-01 0
Total number of active participants reported on line 7a of the Form 5500 2019-12-01 174
Total of all active and inactive participants 2019-12-01 174
Total participants 2019-12-01 174

Measure	Date	Value
2022: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-12-01	177
Total number of active participants reported on line 7a of the Form 5500	2022-12-01	179
Total of all active and inactive participants	2022-12-01	179
Total participants	2022-12-01	179
2021: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-12-01	172
Total number of active participants reported on line 7a of the Form 5500	2021-12-01	177
Total of all active and inactive participants	2021-12-01	177
Total participants	2021-12-01	177
2020: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-12-01	174
Total number of active participants reported on line 7a of the Form 5500	2020-12-01	172
Total of all active and inactive participants	2020-12-01	172
Total participants	2020-12-01	172
2019: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-12-01	0
Total number of active participants reported on line 7a of the Form 5500	2019-12-01	174
Total of all active and inactive participants	2019-12-01	174
Total participants	2019-12-01	174

Form 5500 Responses for KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN

2022: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-12-01	Type of plan entity	Single employer plan
2022-12-01	Plan funding arrangement – Insurance	Yes
2022-12-01	Plan benefit arrangement – Insurance	Yes
2021: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-12-01	Type of plan entity	Single employer plan
2021-12-01	Plan funding arrangement – Insurance	Yes
2021-12-01	Plan benefit arrangement – Insurance	Yes
2020: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-12-01	Type of plan entity	Single employer plan
2020-12-01	Plan funding arrangement – Insurance	Yes
2020-12-01	Plan benefit arrangement – Insurance	Yes
2019: KEYSTONE COLLECTIONS GROUP WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-12-01	Type of plan entity	Single employer plan
2019-12-01	First time form 5500 has been submitted	Yes
2019-12-01	Plan funding arrangement – Insurance	Yes
2019-12-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

021561NC7

Policy instance

Insurance contract or identification number	021561NC7
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

025161NC3

Policy instance

Insurance contract or identification number	025161NC3
Dental Insurance Welfare Benefit	Yes
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 BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )

Policy contract number

021561NN5

Policy instance

Insurance contract or identification number	021561NN5
Number of Individuals Covered	2
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $21
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21
Insurance broker organization code?	3

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

Policy contract number

021561NC5

Policy instance

Insurance contract or identification number	021561NC5
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC6

Policy instance

Insurance contract or identification number	021561NC6
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

025161NC8

Policy instance

Insurance contract or identification number	025161NC8
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC9

Policy instance

Insurance contract or identification number	021561NC9
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561ND0

Policy instance

Insurance contract or identification number	021561ND0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN0

Policy instance

Insurance contract or identification number	021561NN0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC2

Policy instance

Insurance contract or identification number	021561NC2
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561905

Policy instance

Insurance contract or identification number	021561905
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561904

Policy instance

Insurance contract or identification number	021561904
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

021561NO1

Policy instance

Insurance contract or identification number	021561NO1
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN9

Policy instance

Insurance contract or identification number	021561NN9
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NO0

Policy instance

Insurance contract or identification number	021561NO0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN7

Policy instance

Insurance contract or identification number	021561NN7
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561302

Policy instance

Insurance contract or identification number	021561302
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561301

Policy instance

Insurance contract or identification number	021561301
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561802

Policy instance

Insurance contract or identification number	021561802
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

021561803

Policy instance

Insurance contract or identification number	021561803
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN1

Policy instance

Insurance contract or identification number	021561NN1
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN2

Policy instance

Insurance contract or identification number	021561NN2
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN3

Policy instance

Insurance contract or identification number	021561NN3
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561803

Policy instance

Insurance contract or identification number	021561803
Number of Individuals Covered	49
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $6,718
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $246,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,718
Insurance broker organization code?	3

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

Policy contract number

021561904

Policy instance

Insurance contract or identification number	021561904
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC6

Policy instance

Insurance contract or identification number	021561NC6
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN0

Policy instance

Insurance contract or identification number	021561NN0
Number of Individuals Covered	48
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $626
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $626
Insurance broker organization code?	3

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

Policy contract number

021561NN1

Policy instance

Insurance contract or identification number	021561NN1
Number of Individuals Covered	2
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $30
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $296
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
Insurance broker organization code?	3

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

Policy contract number

021561NN2

Policy instance

Insurance contract or identification number	021561NN2
Number of Individuals Covered	21
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $491
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $491
Insurance broker organization code?	3

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

Policy contract number

021561NN3

Policy instance

Insurance contract or identification number	021561NN3
Number of Individuals Covered	1
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $79
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $79
Insurance broker organization code?	3

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

Policy contract number

021561NN4

Policy instance

Insurance contract or identification number	021561NN4
Number of Individuals Covered	58
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $548
Dental Insurance Welfare Benefit	Yes
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 $548
Insurance broker organization code?	3

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

Policy contract number

021561802

Policy instance

Insurance contract or identification number	021561802
Number of Individuals Covered	89
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $14,828
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $551,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,828
Insurance broker organization code?	3

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

Policy contract number

021561NN6

Policy instance

Insurance contract or identification number	021561NN6
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561301

Policy instance

Insurance contract or identification number	021561301
Number of Individuals Covered	4
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $1,095
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,095
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1120407

Policy instance

Insurance contract or identification number	1120407
Number of Individuals Covered	179
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $3,645
Total amount of fees paid to insurance company	USD $522
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,625
Amount paid for insurance broker fees	522
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

021561NN4

Policy instance

Insurance contract or identification number	021561NN4
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN5

Policy instance

Insurance contract or identification number	021561NN5
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN6

Policy instance

Insurance contract or identification number	021561NN6
Number of Individuals Covered	67
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $2,334
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,334
Insurance broker organization code?	3

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

Policy contract number

021561NN7

Policy instance

Insurance contract or identification number	021561NN7
Number of Individuals Covered	1
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $41
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41

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

Policy contract number

021561NO0

Policy instance

Insurance contract or identification number	021561NO0
Number of Individuals Covered	13
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $449
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $449
Insurance broker organization code?	3

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

Policy contract number

021561NN8

Policy instance

Insurance contract or identification number	021561NN8
Number of Individuals Covered	10
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $207
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $207
Insurance broker organization code?	3

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

Policy contract number

021561303

Policy instance

Insurance contract or identification number	021561303
Number of Individuals Covered	31
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $4,672
Welfare Benefit Premiums Paid to Carrier	USD $171,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,672
Insurance broker organization code?	3

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

Policy contract number

021561304

Policy instance

Insurance contract or identification number	021561304
Number of Individuals Covered	2
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $652
Welfare Benefit Premiums Paid to Carrier	USD $23,440
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $652

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

Policy contract number

021561NN3

Policy instance

Insurance contract or identification number	021561NN3
Number of Individuals Covered	1
Total amount of commissions paid to insurance broker	USD $60
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $605
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $60
Insurance broker organization code?	3

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

Policy contract number

021561302

Policy instance

Insurance contract or identification number	021561302
Total amount of commissions paid to insurance broker	USD $200
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $200
Insurance broker organization code?	3

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

Policy contract number

021561301

Policy instance

Insurance contract or identification number	021561301
Number of Individuals Covered	4
Total amount of commissions paid to insurance broker	USD $734
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $734
Insurance broker organization code?	3

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

Policy contract number

021561802

Policy instance

Insurance contract or identification number	021561802
Number of Individuals Covered	85
Total amount of commissions paid to insurance broker	USD $14,620
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $495,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,620
Insurance broker organization code?	3

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

Policy contract number

021561NN4

Policy instance

Insurance contract or identification number	021561NN4
Number of Individuals Covered	52
Total amount of commissions paid to insurance broker	USD $411
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $411
Insurance broker organization code?	3

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

Policy contract number

021561NN5

Policy instance

Insurance contract or identification number	021561NN5
Number of Individuals Covered	3
Total amount of commissions paid to insurance broker	USD $23
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23
Insurance broker organization code?	3

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

Policy contract number

021561NN6

Policy instance

Insurance contract or identification number	021561NN6
Number of Individuals Covered	76
Total amount of commissions paid to insurance broker	USD $2,193
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,193
Insurance broker organization code?	3

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

Policy contract number

021561NN7

Policy instance

Insurance contract or identification number	021561NN7
Total amount of commissions paid to insurance broker	USD $3
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35
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

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

Policy contract number

021561NO0

Policy instance

Insurance contract or identification number	021561NO0
Number of Individuals Covered	5
Total amount of commissions paid to insurance broker	USD $155
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,563
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
Insurance broker organization code?	3

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

Policy contract number

021561NN9

Policy instance

Insurance contract or identification number	021561NN9
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NO1

Policy instance

Insurance contract or identification number	021561NO1
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN8

Policy instance

Insurance contract or identification number	021561NN8
Number of Individuals Covered	7
Total amount of commissions paid to insurance broker	USD $114
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $114
Insurance broker organization code?	3

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

Policy contract number

021561303

Policy instance

Insurance contract or identification number	021561303
Number of Individuals Covered	31
Total amount of commissions paid to insurance broker	USD $4,853
Welfare Benefit Premiums Paid to Carrier	USD $163,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,853
Insurance broker organization code?	3

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

Policy contract number

021561304

Policy instance

Insurance contract or identification number	021561304
Number of Individuals Covered	2
Total amount of commissions paid to insurance broker	USD $746
Welfare Benefit Premiums Paid to Carrier	USD $25,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $746

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

Policy contract number

021561906

Policy instance

Insurance contract or identification number	021561906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN2

Policy instance

Insurance contract or identification number	021561NN2
Number of Individuals Covered	12
Total amount of commissions paid to insurance broker	USD $392
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $392
Insurance broker organization code?	3

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

Policy contract number

021561NN1

Policy instance

Insurance contract or identification number	021561NN1
Number of Individuals Covered	2
Total amount of commissions paid to insurance broker	USD $25
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25
Insurance broker organization code?	3

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

Policy contract number

021561NN0

Policy instance

Insurance contract or identification number	021561NN0
Number of Individuals Covered	53
Total amount of commissions paid to insurance broker	USD $562
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $562
Insurance broker organization code?	3

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

Policy contract number

021561803

Policy instance

Insurance contract or identification number	021561803
Number of Individuals Covered	54
Total amount of commissions paid to insurance broker	USD $6,755
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $224,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,755
Insurance broker organization code?	3

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

Policy contract number

021561904

Policy instance

Insurance contract or identification number	021561904
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561905

Policy instance

Insurance contract or identification number	021561905
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC2

Policy instance

Insurance contract or identification number	021561NC2
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

025161NC3

Policy instance

Insurance contract or identification number	025161NC3
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC5

Policy instance

Insurance contract or identification number	021561NC5
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC0

Policy instance

Insurance contract or identification number	021561NC0
Total amount of commissions paid to insurance broker	USD $3
Dental Insurance Welfare Benefit	Yes
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 $3
Insurance broker organization code?	3

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

Policy contract number

021561NC7

Policy instance

Insurance contract or identification number	021561NC7
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

025161NC8

Policy instance

Insurance contract or identification number	025161NC8
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC9

Policy instance

Insurance contract or identification number	021561NC9
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561ND0

Policy instance

Insurance contract or identification number	021561ND0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561907

Policy instance

Insurance contract or identification number	021561907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1120407

Policy instance

Insurance contract or identification number	1120407
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $3,740
Total amount of fees paid to insurance company	USD $723
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,634
Amount paid for insurance broker fees	723
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

021561NC5

Policy instance

Insurance contract or identification number	021561NC5
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

025161NC3

Policy instance

Insurance contract or identification number	025161NC3
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC2

Policy instance

Insurance contract or identification number	021561NC2
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561905

Policy instance

Insurance contract or identification number	021561905
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561904

Policy instance

Insurance contract or identification number	021561904
Number of Individuals Covered	1
Total amount of commissions paid to insurance broker	USD $84
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63
Insurance broker organization code?	3

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

Policy contract number

021561803

Policy instance

Insurance contract or identification number	021561803
Number of Individuals Covered	52
Total amount of commissions paid to insurance broker	USD $5,856
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $200,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,347
Insurance broker organization code?	3

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

Policy contract number

021561802

Policy instance

Insurance contract or identification number	021561802
Number of Individuals Covered	81
Total amount of commissions paid to insurance broker	USD $11,310
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $378,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,314
Insurance broker organization code?	3

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

Policy contract number

021561302

Policy instance

Insurance contract or identification number	021561302
Number of Individuals Covered	3
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $551
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $413
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1120407

Policy instance

Insurance contract or identification number	1120407
Number of Individuals Covered	172
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $3,763
Total amount of fees paid to insurance company	USD $316
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,002
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
Amount paid for insurance broker fees	316
Additional information about fees paid to insurance broker	BONUS

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

Policy contract number

021561NN8

Policy instance

Insurance contract or identification number	021561NN8
Number of Individuals Covered	7
Total amount of commissions paid to insurance broker	USD $117
Dental Insurance Welfare Benefit	Yes
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 $88

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

Policy contract number

021561NO1

Policy instance

Insurance contract or identification number	021561NO1
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561301

Policy instance

Insurance contract or identification number	021561301
Number of Individuals Covered	2
Total amount of commissions paid to insurance broker	USD $460
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $378
Insurance broker organization code?	3

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

Policy contract number

021561NC0

Policy instance

Insurance contract or identification number	021561NC0
Number of Individuals Covered	1
Total amount of commissions paid to insurance broker	USD $4
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3
Insurance broker organization code?	3

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

Policy contract number

021561NC7

Policy instance

Insurance contract or identification number	021561NC7
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

025161NC8

Policy instance

Insurance contract or identification number	025161NC8
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN9

Policy instance

Insurance contract or identification number	021561NN9
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NO0

Policy instance

Insurance contract or identification number	021561NO0
Number of Individuals Covered	5
Total amount of commissions paid to insurance broker	USD $37
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28
Insurance broker organization code?	3

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

Policy contract number

021561NN7

Policy instance

Insurance contract or identification number	021561NN7
Total amount of commissions paid to insurance broker	USD $21
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21
Insurance broker organization code?	3

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

Policy contract number

021561NN6

Policy instance

Insurance contract or identification number	021561NN6
Number of Individuals Covered	71
Total amount of commissions paid to insurance broker	USD $2,083
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,537
Insurance broker organization code?	3

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

Policy contract number

021561NN5

Policy instance

Insurance contract or identification number	021561NN5
Number of Individuals Covered	2
Total amount of commissions paid to insurance broker	USD $10
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $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 $6
Insurance broker organization code?	3

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

Policy contract number

021561NN4

Policy instance

Insurance contract or identification number	021561NN4
Number of Individuals Covered	57
Total amount of commissions paid to insurance broker	USD $520
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $394
Insurance broker organization code?	3

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

Policy contract number

021561NN3

Policy instance

Insurance contract or identification number	021561NN3
Number of Individuals Covered	3
Total amount of commissions paid to insurance broker	USD $100
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $75
Insurance broker organization code?	3

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

Policy contract number

021561ND0

Policy instance

Insurance contract or identification number	021561ND0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN0

Policy instance

Insurance contract or identification number	021561NN0
Number of Individuals Covered	46
Total amount of commissions paid to insurance broker	USD $463
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $342
Insurance broker organization code?	3

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

Policy contract number

021561NN1

Policy instance

Insurance contract or identification number	021561NN1
Number of Individuals Covered	2
Total amount of commissions paid to insurance broker	USD $22
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $248
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
Insurance broker organization code?	3

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

Policy contract number

021561NN2

Policy instance

Insurance contract or identification number	021561NN2
Number of Individuals Covered	19
Total amount of commissions paid to insurance broker	USD $601
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $454
Insurance broker organization code?	3

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

Policy contract number

021561NC9

Policy instance

Insurance contract or identification number	021561NC9
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC7

Policy instance

Insurance contract or identification number	021561NC7
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC6

Policy instance

Insurance contract or identification number	021561NC6
Total amount of commissions paid to insurance broker	USD $30
Welfare Benefit Premiums Paid to Carrier	USD $358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24
Insurance broker organization code?	7

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

Policy contract number

021561NC5

Policy instance

Insurance contract or identification number	021561NC5
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

025161NC3

Policy instance

Insurance contract or identification number	025161NC3
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NC2

Policy instance

Insurance contract or identification number	021561NC2
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561905

Policy instance

Insurance contract or identification number	021561905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561904

Policy instance

Insurance contract or identification number	021561904
Number of Individuals Covered	1
Total amount of commissions paid to insurance broker	USD $193
Welfare Benefit Premiums Paid to Carrier	USD $6,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $105
Insurance broker organization code?	3

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

Policy contract number

021561803

Policy instance

Insurance contract or identification number	021561803
Number of Individuals Covered	46
Total amount of commissions paid to insurance broker	USD $4,647
Welfare Benefit Premiums Paid to Carrier	USD $158,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,190
Insurance broker organization code?	3

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

Policy contract number

021561802

Policy instance

Insurance contract or identification number	021561802
Number of Individuals Covered	84
Total amount of commissions paid to insurance broker	USD $14,067
Welfare Benefit Premiums Paid to Carrier	USD $432,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,663
Insurance broker organization code?	3

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

Policy contract number

021561301

Policy instance

Insurance contract or identification number	021561301
Number of Individuals Covered	2
Total amount of commissions paid to insurance broker	USD $652
Welfare Benefit Premiums Paid to Carrier	USD $14,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $339
Insurance broker organization code?	3

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

Policy contract number

021561302

Policy instance

Insurance contract or identification number	021561302
Number of Individuals Covered	3
Total amount of commissions paid to insurance broker	USD $505
Welfare Benefit Premiums Paid to Carrier	USD $19,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $367
Insurance broker organization code?	3

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

Policy contract number

021561NC9

Policy instance

Insurance contract or identification number	021561NC9
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561ND0

Policy instance

Insurance contract or identification number	021561ND0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1120407

Policy instance

Insurance contract or identification number	1120407
Number of Individuals Covered	174
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $3,466
Total amount of fees paid to insurance company	USD $304
Welfare Benefit Premiums Paid to Carrier	USD $31,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,041
Insurance broker organization code?	3
Amount paid for insurance broker fees	304
Additional information about fees paid to insurance broker	BONUS

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

Policy contract number

021561NO1

Policy instance

Insurance contract or identification number	021561NO1
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN9

Policy instance

Insurance contract or identification number	021561NN9
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NO0

Policy instance

Insurance contract or identification number	021561NO0
Number of Individuals Covered	1
Total amount of commissions paid to insurance broker	USD $57
Welfare Benefit Premiums Paid to Carrier	USD $533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32
Insurance broker organization code?	3

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

Policy contract number

021561NN7

Policy instance

Insurance contract or identification number	021561NN7
Number of Individuals Covered	1
Total amount of commissions paid to insurance broker	USD $62
Welfare Benefit Premiums Paid to Carrier	USD $655
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
Insurance broker organization code?	3

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

Policy contract number

021561NN6

Policy instance

Insurance contract or identification number	021561NN6
Number of Individuals Covered	59
Total amount of commissions paid to insurance broker	USD $1,680
Welfare Benefit Premiums Paid to Carrier	USD $18,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,136
Insurance broker organization code?	3

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

Policy contract number

021561NN5

Policy instance

Insurance contract or identification number	021561NN5
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

021561NN4

Policy instance

Insurance contract or identification number	021561NN4
Number of Individuals Covered	59
Total amount of commissions paid to insurance broker	USD $548
Welfare Benefit Premiums Paid to Carrier	USD $5,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $361
Insurance broker organization code?	3

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

Policy contract number

021561NN3

Policy instance

Insurance contract or identification number	021561NN3
Number of Individuals Covered	3
Total amount of commissions paid to insurance broker	USD $100
Welfare Benefit Premiums Paid to Carrier	USD $1,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67
Insurance broker organization code?	3

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

Policy contract number

021561NN2

Policy instance

Insurance contract or identification number	021561NN2
Number of Individuals Covered	28
Total amount of commissions paid to insurance broker	USD $694
Welfare Benefit Premiums Paid to Carrier	USD $7,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $468
Insurance broker organization code?	3
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Amount paid for insurance broker fees	0

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

Policy contract number

021561NN1

Policy instance

Insurance contract or identification number	021561NN1
Number of Individuals Covered	1
Total amount of commissions paid to insurance broker	USD $12
Welfare Benefit Premiums Paid to Carrier	USD $123
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8
Insurance broker organization code?	3

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

Policy contract number

021561NN0

Policy instance

Insurance contract or identification number	021561NN0
Number of Individuals Covered	45
Total amount of commissions paid to insurance broker	USD $493
Welfare Benefit Premiums Paid to Carrier	USD $5,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $334
Insurance broker organization code?	3

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

Policy contract number

025161NC8

Policy instance

Insurance contract or identification number	025161NC8
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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Company Name:	KRATZENBERG & ASSOCIATES INC.
Employer identification number (EIN):	251780727
NAIC Classification:	541219
NAIC Description:	Other Accounting Services