KIRWAN SURGICAL PRODUCTS LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN
401k plan membership statisitcs for KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-06-15 | 136 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-06-15 | 144 |
| Number of retired or separated participants receiving benefits | 2022-06-15 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-06-15 | 0 |
| Total of all active and inactive participants | 2022-06-15 | 144 |
| 2021: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-06-15 | 135 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-06-15 | 136 |
| Number of retired or separated participants receiving benefits | 2021-06-15 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-06-15 | 0 |
| Total of all active and inactive participants | 2021-06-15 | 136 |
| 2020: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-06-15 | 134 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-06-15 | 135 |
| Number of retired or separated participants receiving benefits | 2020-06-15 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-06-15 | 0 |
| Total of all active and inactive participants | 2020-06-15 | 135 |
| 2019: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-06-15 | 129 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-06-15 | 134 |
| Number of retired or separated participants receiving benefits | 2019-06-15 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-06-15 | 0 |
| Total of all active and inactive participants | 2019-06-15 | 134 |
| 2018: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-06-15 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-06-15 | 128 |
| Number of retired or separated participants receiving benefits | 2018-06-15 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2018-06-15 | 0 |
| Total of all active and inactive participants | 2018-06-15 | 129 |
| 2017: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-06-15 | 119 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-06-15 | 118 |
| Number of retired or separated participants receiving benefits | 2017-06-15 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-06-15 | 0 |
| Total of all active and inactive participants | 2017-06-15 | 118 |
| 2016: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-06-15 | 117 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-06-15 | 119 |
| Number of retired or separated participants receiving benefits | 2016-06-15 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-06-15 | 0 |
| Total of all active and inactive participants | 2016-06-15 | 119 |
| 2015: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-06-15 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-06-15 | 114 |
| Number of retired or separated participants receiving benefits | 2015-06-15 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2015-06-15 | 0 |
| Total of all active and inactive participants | 2015-06-15 | 117 |
| 2014: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-06-15 | 103 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-06-15 | 112 |
| Number of retired or separated participants receiving benefits | 2014-06-15 | 1 |
| Total of all active and inactive participants | 2014-06-15 | 113 |
| 2013: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-06-15 | 101 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-06-15 | 104 |
| Number of retired or separated participants receiving benefits | 2013-06-15 | 1 |
| Total of all active and inactive participants | 2013-06-15 | 105 |
| 2022: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-06-15 | Type of plan entity | Single employer plan |
| 2022-06-15 | Submission has been amended | No |
| 2022-06-15 | This submission is the final filing | No |
| 2022-06-15 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-06-15 | Plan is a collectively bargained plan | No |
| 2022-06-15 | Plan funding arrangement – Insurance | Yes |
| 2022-06-15 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-06-15 | Plan benefit arrangement – Insurance | Yes |
| 2022-06-15 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-06-15 | Type of plan entity | Single employer plan |
| 2021-06-15 | Submission has been amended | No |
| 2021-06-15 | This submission is the final filing | No |
| 2021-06-15 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-06-15 | Plan is a collectively bargained plan | No |
| 2021-06-15 | Plan funding arrangement – Insurance | Yes |
| 2021-06-15 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-06-15 | Plan benefit arrangement – Insurance | Yes |
| 2021-06-15 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-06-15 | Type of plan entity | Single employer plan |
| 2020-06-15 | Submission has been amended | No |
| 2020-06-15 | This submission is the final filing | No |
| 2020-06-15 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-06-15 | Plan is a collectively bargained plan | No |
| 2020-06-15 | Plan funding arrangement – Insurance | Yes |
| 2020-06-15 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-06-15 | Plan benefit arrangement – Insurance | Yes |
| 2020-06-15 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-06-15 | Type of plan entity | Single employer plan |
| 2019-06-15 | Submission has been amended | No |
| 2019-06-15 | This submission is the final filing | No |
| 2019-06-15 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-06-15 | Plan is a collectively bargained plan | No |
| 2019-06-15 | Plan funding arrangement – Insurance | Yes |
| 2019-06-15 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-06-15 | Plan benefit arrangement – Insurance | Yes |
| 2019-06-15 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-06-15 | Type of plan entity | Single employer plan |
| 2018-06-15 | Submission has been amended | No |
| 2018-06-15 | This submission is the final filing | No |
| 2018-06-15 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-06-15 | Plan is a collectively bargained plan | No |
| 2018-06-15 | Plan funding arrangement – Insurance | Yes |
| 2018-06-15 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-06-15 | Plan benefit arrangement – Insurance | Yes |
| 2018-06-15 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-06-15 | Type of plan entity | Single employer plan |
| 2017-06-15 | Submission has been amended | No |
| 2017-06-15 | This submission is the final filing | No |
| 2017-06-15 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-06-15 | Plan is a collectively bargained plan | No |
| 2017-06-15 | Plan funding arrangement – Insurance | Yes |
| 2017-06-15 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-06-15 | Plan benefit arrangement – Insurance | Yes |
| 2017-06-15 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-06-15 | Type of plan entity | Single employer plan |
| 2016-06-15 | Submission has been amended | No |
| 2016-06-15 | This submission is the final filing | No |
| 2016-06-15 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-06-15 | Plan is a collectively bargained plan | No |
| 2016-06-15 | Plan funding arrangement – Insurance | Yes |
| 2016-06-15 | Plan benefit arrangement – Insurance | Yes |
| 2015: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-06-15 | Type of plan entity | Single employer plan |
| 2015-06-15 | Submission has been amended | No |
| 2015-06-15 | This submission is the final filing | No |
| 2015-06-15 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-06-15 | Plan is a collectively bargained plan | No |
| 2015-06-15 | Plan funding arrangement – Insurance | Yes |
| 2015-06-15 | Plan benefit arrangement – Insurance | Yes |
| 2014: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-06-15 | Type of plan entity | Single employer plan |
| 2014-06-15 | Submission has been amended | No |
| 2014-06-15 | This submission is the final filing | No |
| 2014-06-15 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-06-15 | Plan is a collectively bargained plan | No |
| 2014-06-15 | Plan funding arrangement – Insurance | Yes |
| 2014-06-15 | Plan benefit arrangement – Insurance | Yes |
| 2013: KIRWAN SURGICAL PRODUCTS LLC GROUP HEALTH & WELFARE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-06-15 | Type of plan entity | Single employer plan |
| 2013-06-15 | First time form 5500 has been submitted | Yes |
| 2013-06-15 | Submission has been amended | No |
| 2013-06-15 | This submission is the final filing | No |
| 2013-06-15 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-06-15 | Plan is a collectively bargained plan | No |
| 2013-06-15 | Plan funding arrangement – Insurance | Yes |
| 2013-06-15 | Plan benefit arrangement – Insurance | Yes |
| TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 ) |
| Policy contract number | 080603094456 |
| Policy instance | 5 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2022-06-15 | | Insurance policy end date | 2023-06-14 | | Total amount of commissions paid to insurance broker | USD $1,311 | | Total amount of fees paid to insurance company | USD $143 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $31,098 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,311 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 143 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION PAID |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 080603094456 |
| Policy instance | 4 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2022-06-15 | | Insurance policy end date | 2023-06-14 | | Total amount of commissions paid to insurance broker | USD $76,780 | | Total amount of fees paid to insurance company | USD $12,182 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,768,810 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $76,780 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 12182 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION PAID |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 31827 |
| Policy instance | 3 |
| Insurance contract or identification number | 31827 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2022-06-15 | | Insurance policy end date | 2023-06-14 | | Total amount of commissions paid to insurance broker | USD $478 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,499 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $478 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956607 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956607 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2022-06-15 | | Insurance policy end date | 2023-06-14 | | Total amount of commissions paid to insurance broker | USD $6,562 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $6,562 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 931741 |
| Policy instance | 1 |
| Insurance contract or identification number | 931741 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2022-06-15 | | Insurance policy end date | 2023-06-14 | | Total amount of commissions paid to insurance broker | USD $12,671 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $84,513 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,671 | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 31827 |
| Policy instance | 3 |
| Insurance contract or identification number | 31827 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2021-06-15 | | Insurance policy end date | 2022-06-14 | | Total amount of commissions paid to insurance broker | USD $825 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,252 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $825 | | Insurance broker organization code? | 3 |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 080603094456 |
| Policy instance | 4 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 216 | | Insurance policy start date | 2021-06-15 | | Insurance policy end date | 2022-06-14 | | Total amount of commissions paid to insurance broker | USD $59,963 | | Total amount of fees paid to insurance company | USD $12,182 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,649,761 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $59,963 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 12182 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION PAID |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 931741 |
| Policy instance | 1 |
| Insurance contract or identification number | 931741 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2021-06-15 | | Insurance policy end date | 2022-06-14 | | Total amount of commissions paid to insurance broker | USD $11,079 | | Total amount of fees paid to insurance company | USD $1,084 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $73,774 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,079 | | Amount paid for insurance broker fees | 1084 | | Additional information about fees paid to insurance broker | BONUS AND ADDITIONAL PAYMENTS | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956607 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956607 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2021-06-15 | | Insurance policy end date | 2022-06-14 | | Total amount of commissions paid to insurance broker | USD $6,553 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $109,019 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,553 | | Insurance broker organization code? | 3 |
|
| TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 ) |
| Policy contract number | 080603094456 |
| Policy instance | 5 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2021-06-15 | | Insurance policy end date | 2022-06-14 | | Total amount of commissions paid to insurance broker | USD $777 | | Total amount of fees paid to insurance company | USD $143 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $-120,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $777 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 143 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION PAID |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 931741 |
| Policy instance | 1 |
| Insurance contract or identification number | 931741 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2020-06-15 | | Insurance policy end date | 2021-06-14 | | Total amount of commissions paid to insurance broker | USD $12,856 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $85,830 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,856 | | Insurance broker organization code? | 3 |
|
| TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 ) |
| Policy contract number | 080603094456 |
| Policy instance | 5 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2020-06-15 | | Insurance policy end date | 2021-06-14 | | Total amount of commissions paid to insurance broker | USD $680 | | Total amount of fees paid to insurance company | USD $255 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $18,628 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $680 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 255 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION PAID |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 31827 |
| Policy instance | 3 |
| Insurance contract or identification number | 31827 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2020-06-15 | | Insurance policy end date | 2021-06-14 | | Total amount of commissions paid to insurance broker | USD $649 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,487 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $649 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956607 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956607 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2020-06-15 | | Insurance policy end date | 2021-06-14 | | Total amount of commissions paid to insurance broker | USD $6,387 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 | | Commission paid to Insurance Broker | USD $6,387 | | Insurance broker organization code? | 3 |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 080603094456 |
| Policy instance | 4 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2020-06-15 | | Insurance policy end date | 2021-06-14 | | Total amount of commissions paid to insurance broker | USD $58,222 | | Total amount of fees paid to insurance company | USD $20,862 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,595,508 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $58,222 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 20862 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION PAID |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 080603094456 |
| Policy instance | 4 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2019-06-15 | | Insurance policy end date | 2020-06-14 | | Total amount of commissions paid to insurance broker | USD $66,044 | | Total amount of fees paid to insurance company | USD $17,524 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,421,182 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $66,044 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 17524 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION PAID |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 31827 |
| Policy instance | 3 |
| Insurance contract or identification number | 31827 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2019-06-15 | | Insurance policy end date | 2020-06-14 | | Total amount of commissions paid to insurance broker | USD $680 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,799 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $680 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956607 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956607 | | Number of Individuals Covered | 199 | | Insurance policy start date | 2019-06-15 | | Insurance policy end date | 2020-06-14 | | Total amount of commissions paid to insurance broker | USD $6,901 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 | | Commission paid to Insurance Broker | USD $6,901 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 931741 |
| Policy instance | 1 |
| Insurance contract or identification number | 931741 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2019-06-15 | | Insurance policy end date | 2020-06-14 | | Total amount of commissions paid to insurance broker | USD $13,938 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $92,797 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,713 | | Insurance broker organization code? | 3 |
|
| TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 ) |
| Policy contract number | 080603094456 |
| Policy instance | 5 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2019-06-15 | | Insurance policy end date | 2020-06-14 | | Total amount of commissions paid to insurance broker | USD $799 | | Total amount of fees paid to insurance company | USD $174 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $18,515 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $799 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 174 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION PAID |
|
| TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 ) |
| Policy contract number | 080603094456 |
| Policy instance | 5 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2018-06-15 | | Insurance policy end date | 2019-06-14 | | Total amount of commissions paid to insurance broker | USD $339 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $12,471 | | 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 |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 080603094456 |
| Policy instance | 4 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2018-06-15 | | Insurance policy end date | 2019-06-14 | | Total amount of commissions paid to insurance broker | USD $36,041 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,324,942 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,041 | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 31827 |
| Policy instance | 3 |
| Insurance contract or identification number | 31827 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2018-06-15 | | Insurance policy end date | 2019-06-14 | | Total amount of commissions paid to insurance broker | USD $671 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,714 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $671 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956607 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956607 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2018-06-15 | | Insurance policy end date | 2019-06-14 | | Total amount of commissions paid to insurance broker | USD $6,931 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 | | Commission paid to Insurance Broker | USD $6,931 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 158401 |
| Policy instance | 1 |
| Insurance contract or identification number | 158401 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2018-06-15 | | Insurance policy end date | 2019-06-14 | | Total amount of commissions paid to insurance broker | USD $13,224 | | Total amount of fees paid to insurance company | USD $1,703 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 | | Commission paid to Insurance Broker | USD $13,224 | | Amount paid for insurance broker fees | 1703 | | Additional information about fees paid to insurance broker | CONTINGENT COMP | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956607 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956607 | | Number of Individuals Covered | 192 | | Insurance policy start date | 2017-06-15 | | Insurance policy end date | 2018-06-14 | | Total amount of commissions paid to insurance broker | USD $6,222 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $104,479 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,222 | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| NATIONAL GUARDIAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 31827 |
| Policy instance | 3 |
| Insurance contract or identification number | 31827 | | Number of Individuals Covered | 74 | | Insurance policy start date | 2017-06-15 | | Insurance policy end date | 2018-06-14 | | Total amount of commissions paid to insurance broker | USD $360 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $360 | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP INC |
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| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 080603094456 |
| Policy instance | 4 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 212 | | Insurance policy start date | 2017-06-15 | | Insurance policy end date | 2018-06-14 | | Total amount of commissions paid to insurance broker | USD $27,180 | | Total amount of fees paid to insurance company | USD $7,480 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,182,617 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,180 | | Amount paid for insurance broker fees | 7480 | | Additional information about fees paid to insurance broker | OTHER COMP PAID | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC |
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| TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 ) |
| Policy contract number | 080603094456 |
| Policy instance | 5 |
| Insurance contract or identification number | 080603094456 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2017-06-15 | | Insurance policy end date | 2018-06-14 | | Total amount of commissions paid to insurance broker | USD $531 | | Total amount of fees paid to insurance company | USD $76 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $25,822 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $531 | | Amount paid for insurance broker fees | 76 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
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| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | R19583-000 |
| Policy instance | 6 |
| Insurance contract or identification number | R19583-000 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2017-06-15 | | Insurance policy end date | 2018-06-14 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | NYDBL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $205 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
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| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 158401 |
| Policy instance | 1 |
| Insurance contract or identification number | 158401 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2017-06-15 | | Insurance policy end date | 2018-06-14 | | Total amount of commissions paid to insurance broker | USD $11,954 | | Total amount of fees paid to insurance company | USD $3,170 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 | | Commission paid to Insurance Broker | USD $11,954 | | Amount paid for insurance broker fees | 3170 | | Additional information about fees paid to insurance broker | CONTINGENT COMP | | Insurance broker organization code? | 3 | | Insurance broker name | HAYS BENEFITS GROUP LLC |
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