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TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 401k Plan overview

Plan NameTEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN
Plan identification number 501

TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

TEUFELBERGER FIBER ROPE CORP. has sponsored the creation of one or more 401k plans.

Company Name:TEUFELBERGER FIBER ROPE CORP.
Employer identification number (EIN):260333709
NAIC Classification:314000
NAIC Description: Textile Product Mills

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-02-01PAMELA SCHMIDT2023-08-11
5012021-02-01PAMELA SCHMIDT2022-08-22
5012020-02-01MAUREEN GRIFFIN2021-11-11
5012020-02-01MAUREEN GIFFIN2022-01-31
5012019-02-01JOHN TAVARES2020-06-26
5012018-02-01
5012017-02-01
5012016-02-01
5012015-02-01TRUDY JO WALLACH
5012014-02-01TRUDY JO WALLACH
5012013-02-01TRUDY JO WALLACH
5012012-02-01TRUDY JO WALLACH
5012011-02-01ROBERT FONTAINE
5012010-02-01ROBERT FONTAINE
5012009-02-01ROBERT FONTAINE
5012007-02-01ROBERT FONTAINE

Plan Statistics for TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN

401k plan membership statisitcs for TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN

Measure Date Value
2022: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-02-01199
Total number of active participants reported on line 7a of the Form 55002022-02-01182
Number of retired or separated participants receiving benefits2022-02-010
Number of other retired or separated participants entitled to future benefits2022-02-010
Total of all active and inactive participants2022-02-01182
Number of employers contributing to the scheme2022-02-010
2021: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-02-01101
Total number of active participants reported on line 7a of the Form 55002021-02-01199
Number of retired or separated participants receiving benefits2021-02-010
Number of other retired or separated participants entitled to future benefits2021-02-010
Total of all active and inactive participants2021-02-01199
Number of employers contributing to the scheme2021-02-010
2020: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-02-01106
Total number of active participants reported on line 7a of the Form 55002020-02-01100
Number of retired or separated participants receiving benefits2020-02-011
Number of other retired or separated participants entitled to future benefits2020-02-010
Total of all active and inactive participants2020-02-01101
Number of employers contributing to the scheme2020-02-010
2019: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-02-01103
Total number of active participants reported on line 7a of the Form 55002019-02-01103
Number of retired or separated participants receiving benefits2019-02-011
Number of other retired or separated participants entitled to future benefits2019-02-010
Total of all active and inactive participants2019-02-01104
Number of employers contributing to the scheme2019-02-010
2018: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-02-01110
Total number of active participants reported on line 7a of the Form 55002018-02-01107
Number of retired or separated participants receiving benefits2018-02-011
Number of other retired or separated participants entitled to future benefits2018-02-010
Total of all active and inactive participants2018-02-01108
Number of employers contributing to the scheme2018-02-010
2017: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-02-01108
Total number of active participants reported on line 7a of the Form 55002017-02-01110
Number of retired or separated participants receiving benefits2017-02-010
Number of other retired or separated participants entitled to future benefits2017-02-010
Total of all active and inactive participants2017-02-01110
2016: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-02-01114
Total number of active participants reported on line 7a of the Form 55002016-02-01108
Number of retired or separated participants receiving benefits2016-02-010
Number of other retired or separated participants entitled to future benefits2016-02-010
Total of all active and inactive participants2016-02-01108
2015: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-02-01114
Total number of active participants reported on line 7a of the Form 55002015-02-01111
Number of retired or separated participants receiving benefits2015-02-011
Number of other retired or separated participants entitled to future benefits2015-02-010
Total of all active and inactive participants2015-02-01112
2014: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-02-01107
Total number of active participants reported on line 7a of the Form 55002014-02-01110
Number of retired or separated participants receiving benefits2014-02-011
Number of other retired or separated participants entitled to future benefits2014-02-010
Total of all active and inactive participants2014-02-01111
2013: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-02-01104
Total number of active participants reported on line 7a of the Form 55002013-02-01105
Number of retired or separated participants receiving benefits2013-02-011
Number of other retired or separated participants entitled to future benefits2013-02-010
Total of all active and inactive participants2013-02-01106
2012: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-02-01104
Total number of active participants reported on line 7a of the Form 55002012-02-01103
Number of retired or separated participants receiving benefits2012-02-010
Number of other retired or separated participants entitled to future benefits2012-02-010
Total of all active and inactive participants2012-02-01103
2011: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-02-01101
Total number of active participants reported on line 7a of the Form 55002011-02-0190
Number of retired or separated participants receiving benefits2011-02-010
Number of other retired or separated participants entitled to future benefits2011-02-010
Total of all active and inactive participants2011-02-0190
2010: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-02-01103
Total number of active participants reported on line 7a of the Form 55002010-02-01101
Number of retired or separated participants receiving benefits2010-02-010
Number of other retired or separated participants entitled to future benefits2010-02-010
Total of all active and inactive participants2010-02-01101
2009: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-02-01115
Total number of active participants reported on line 7a of the Form 55002009-02-01101
Number of retired or separated participants receiving benefits2009-02-010
Number of other retired or separated participants entitled to future benefits2009-02-010
Total of all active and inactive participants2009-02-01101
2007: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2007 401k membership
Total participants, beginning-of-year2007-02-01100
Total number of active participants reported on line 7a of the Form 55002007-02-01114
Number of retired or separated participants receiving benefits2007-02-010
Number of other retired or separated participants entitled to future benefits2007-02-010
Total of all active and inactive participants2007-02-01114

Form 5500 Responses for TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN

2022: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2022 form 5500 responses
2022-02-01Type of plan entitySingle employer plan
2022-02-01Plan funding arrangement – InsuranceYes
2022-02-01Plan benefit arrangement – InsuranceYes
2021: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2021 form 5500 responses
2021-02-01Type of plan entitySingle employer plan
2021-02-01Plan funding arrangement – InsuranceYes
2021-02-01Plan benefit arrangement – InsuranceYes
2020: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2020 form 5500 responses
2020-02-01Type of plan entitySingle employer plan
2020-02-01Submission has been amendedYes
2020-02-01Plan funding arrangement – InsuranceYes
2020-02-01Plan benefit arrangement – InsuranceYes
2019: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2019 form 5500 responses
2019-02-01Type of plan entitySingle employer plan
2019-02-01Plan funding arrangement – InsuranceYes
2019-02-01Plan benefit arrangement – InsuranceYes
2018: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2018 form 5500 responses
2018-02-01Type of plan entitySingle employer plan
2018-02-01Plan funding arrangement – InsuranceYes
2018-02-01Plan benefit arrangement – InsuranceYes
2017: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2017 form 5500 responses
2017-02-01Type of plan entitySingle employer plan
2017-02-01Plan funding arrangement – InsuranceYes
2017-02-01Plan benefit arrangement – InsuranceYes
2016: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2016 form 5500 responses
2016-02-01Type of plan entitySingle employer plan
2016-02-01Submission has been amendedNo
2016-02-01This submission is the final filingNo
2016-02-01This return/report is a short plan year return/report (less than 12 months)No
2016-02-01Plan is a collectively bargained planNo
2016-02-01Plan funding arrangement – InsuranceYes
2016-02-01Plan benefit arrangement – InsuranceYes
2015: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2015 form 5500 responses
2015-02-01Type of plan entitySingle employer plan
2015-02-01Submission has been amendedNo
2015-02-01This submission is the final filingNo
2015-02-01This return/report is a short plan year return/report (less than 12 months)No
2015-02-01Plan is a collectively bargained planNo
2015-02-01Plan funding arrangement – InsuranceYes
2015-02-01Plan benefit arrangement – InsuranceYes
2014: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2014 form 5500 responses
2014-02-01Type of plan entitySingle employer plan
2014-02-01Submission has been amendedNo
2014-02-01This submission is the final filingNo
2014-02-01This return/report is a short plan year return/report (less than 12 months)No
2014-02-01Plan is a collectively bargained planNo
2014-02-01Plan funding arrangement – InsuranceYes
2014-02-01Plan benefit arrangement – InsuranceYes
2013: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2013 form 5500 responses
2013-02-01Type of plan entitySingle employer plan
2013-02-01Submission has been amendedNo
2013-02-01This submission is the final filingNo
2013-02-01This return/report is a short plan year return/report (less than 12 months)No
2013-02-01Plan is a collectively bargained planNo
2013-02-01Plan funding arrangement – InsuranceYes
2013-02-01Plan benefit arrangement – InsuranceYes
2012: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2012 form 5500 responses
2012-02-01Type of plan entitySingle employer plan
2012-02-01Submission has been amendedNo
2012-02-01This submission is the final filingNo
2012-02-01This return/report is a short plan year return/report (less than 12 months)No
2012-02-01Plan is a collectively bargained planNo
2012-02-01Plan funding arrangement – InsuranceYes
2012-02-01Plan benefit arrangement – InsuranceYes
2011: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2011 form 5500 responses
2011-02-01Type of plan entitySingle employer plan
2011-02-01Submission has been amendedNo
2011-02-01This submission is the final filingNo
2011-02-01This return/report is a short plan year return/report (less than 12 months)No
2011-02-01Plan is a collectively bargained planNo
2011-02-01Plan funding arrangement – InsuranceYes
2011-02-01Plan benefit arrangement – InsuranceYes
2010: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2010 form 5500 responses
2010-02-01Type of plan entitySingle employer plan
2010-02-01Submission has been amendedNo
2010-02-01This submission is the final filingNo
2010-02-01This return/report is a short plan year return/report (less than 12 months)No
2010-02-01Plan is a collectively bargained planNo
2010-02-01Plan funding arrangement – InsuranceYes
2010-02-01Plan benefit arrangement – InsuranceYes
2009: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2009 form 5500 responses
2009-02-01Type of plan entitySingle employer plan
2009-02-01Submission has been amendedNo
2009-02-01This submission is the final filingNo
2009-02-01This return/report is a short plan year return/report (less than 12 months)No
2009-02-01Plan is a collectively bargained planNo
2009-02-01Plan funding arrangement – InsuranceYes
2009-02-01Plan benefit arrangement – InsuranceYes
2007: TEUFELBERGER FIBER ROPE CORP. MEDICAL BENEFITS PLAN 2007 form 5500 responses
2007-02-01Type of plan entitySingle employer plan
2007-02-01First time form 5500 has been submittedYes
2007-02-01Submission has been amendedNo
2007-02-01This submission is the final filingNo
2007-02-01This return/report is a short plan year return/report (less than 12 months)No
2007-02-01Plan is a collectively bargained planNo
2007-02-01Plan funding arrangement – InsuranceYes
2007-02-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number920823
Policy instance 1
Insurance contract or identification number920823
Number of Individuals Covered182
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $42,757
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,372,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,757
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0920823
Policy instance 1
Insurance contract or identification number0920823
Number of Individuals Covered199
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $34,447
Total amount of fees paid to insurance companyUSD $1,209
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,094,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,447
Amount paid for insurance broker fees1209
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number920823
Policy instance 1
Insurance contract or identification number920823
Number of Individuals Covered176
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $37,373
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,083,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,373
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0920823
Policy instance 1
Insurance contract or identification number0920823
Number of Individuals Covered100
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4957985
Policy instance 1
Insurance contract or identification number4957985
Number of Individuals Covered173
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $37,559
Total amount of fees paid to insurance companyUSD $2,600
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $37,559
Amount paid for insurance broker fees2600
Additional information about fees paid to insurance brokerOTHER COMMISSION
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4957985
Policy instance 1
Insurance contract or identification number4957985
Number of Individuals Covered175
Insurance policy start date2018-02-01
Insurance policy end date2019-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4957985
Policy instance 1
Insurance contract or identification number4957985
Number of Individuals Covered187
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4957985
Policy instance 1
Insurance contract or identification number4957985
Number of Individuals Covered204
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number20034
Policy instance 1
Insurance contract or identification number20034
Number of Individuals Covered189
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $28,501
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,167,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $28,501
Insurance broker organization code?3
Insurance broker nameSTARKWEATHER AND SHEPLEY, INC.
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number20034
Policy instance 1
Insurance contract or identification number20034
Number of Individuals Covered192
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $23,107
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,077,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $23,107
Insurance broker organization code?3
Insurance broker nameSTARKWEATHER AND SHEPLEY, INC.
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number20034
Policy instance 1
Insurance contract or identification number20034
Number of Individuals Covered193
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $23,957
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,049,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $21,702
Insurance broker organization code?3
Insurance broker nameSTARKWEATHER AND SHEPLEY, INC.
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number20034
Policy instance 1
Insurance contract or identification number20034
Number of Individuals Covered198
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $24,924
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $966,963
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number20034
Policy instance 1
Insurance contract or identification number20034
Number of Individuals Covered194
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Total amount of commissions paid to insurance brokerUSD $26,817
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $996,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4954644
Policy instance 1
Insurance contract or identification number4954644
Number of Individuals Covered234
Insurance policy start date2008-02-01
Insurance policy end date2009-01-31
Total amount of commissions paid to insurance brokerUSD $21,423
Total amount of fees paid to insurance companyUSD $719
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $841,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4954644
Policy instance 1
Insurance contract or identification number4954644
Number of Individuals Covered114
Insurance policy start date2007-02-01
Insurance policy end date2008-01-31
Total amount of commissions paid to insurance brokerUSD $19,828
Total amount of fees paid to insurance companyUSD $6,758
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $774,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes

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