401k Plan data: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN plan

CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 401k Plan overview

Plan Name	CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN
Plan identification number	501

CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN Benefits

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

401k Sponsoring company profile

CARBONE MANAGEMENT GROUP, LLC has sponsored the creation of one or more 401k plans.

Company Name: CARBONE MANAGEMENT GROUP, LLC

Employer identification number (EIN): 300028210

NAIC Classification: 441110
NAIC Description: New Car Dealers

Additional information about CARBONE MANAGEMENT GROUP, LLC

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 2001-11-06

Company Identification Number: 2696663

Legal Registered Office Address: 5700 HORATIO STREET
Oneida
UTICA
United States of America (USA)
13502

More information about CARBONE MANAGEMENT GROUP, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-01-01 ENESSA CARBONE
501 2015-01-01 ENESSA CARBONE
501 2014-01-01 ENESSA CARBONE
501 2013-01-01 ENESSA CARBONE
501 2012-01-01 ENESSA CARBONE
501 2011-01-01 ENESSA CARBONE
501 2010-01-01 ENESSA CARBONE
501 2009-01-01 PAMELA NOTI

Plan id#	Filing Submission Date	Name of Administrator
501	2016-01-01	ENESSA CARBONE
501	2015-01-01	ENESSA CARBONE
501	2014-01-01	ENESSA CARBONE
501	2013-01-01	ENESSA CARBONE
501	2012-01-01	ENESSA CARBONE
501	2011-01-01	ENESSA CARBONE
501	2010-01-01	ENESSA CARBONE
501	2009-01-01	PAMELA NOTI

Plan Statistics for CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN

401k plan membership statisitcs for CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN

Measure Date Value
2016: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
Total participants 2016-01-01 0
2015: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 550
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 570
Total of all active and inactive participants 2015-01-01 570
Total participants 2015-01-01 0
2014: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 545
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 550
Total of all active and inactive participants 2014-01-01 550
Total participants 2014-01-01 0
2013: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 534
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 545
Total of all active and inactive participants 2013-01-01 545
Total participants 2013-01-01 0
2012: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 528
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 534
Total of all active and inactive participants 2012-01-01 534
Total participants 2012-01-01 0
2011: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 549
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 528
Total of all active and inactive participants 2011-01-01 528
Total participants 2011-01-01 528
2010: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 546
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 549
Total of all active and inactive participants 2010-01-01 549
Total participants 2010-01-01 549
2009: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 583
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 546
Total of all active and inactive participants 2009-01-01 546
Total participants 2009-01-01 546

Measure	Date	Value
2016: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
Total participants	2016-01-01	0
2015: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	550
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	570
Total of all active and inactive participants	2015-01-01	570
Total participants	2015-01-01	0
2014: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	545
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	550
Total of all active and inactive participants	2014-01-01	550
Total participants	2014-01-01	0
2013: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	534
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	545
Total of all active and inactive participants	2013-01-01	545
Total participants	2013-01-01	0
2012: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	528
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	534
Total of all active and inactive participants	2012-01-01	534
Total participants	2012-01-01	0
2011: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	549
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	528
Total of all active and inactive participants	2011-01-01	528
Total participants	2011-01-01	528
2010: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	546
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	549
Total of all active and inactive participants	2010-01-01	549
Total participants	2010-01-01	549
2009: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	583
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	546
Total of all active and inactive participants	2009-01-01	546
Total participants	2009-01-01	546

Form 5500 Responses for CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN

2016: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	This submission is the final filing	Yes
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: CARBONE MANAGEMENT GROUP AND AFFILIATES HEALTH INSURANCE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

FJ274

Policy instance

Insurance contract or identification number	FJ274
Number of Individuals Covered	48
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,774
Total amount of fees paid to insurance company	USD $85
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,803
Amount paid for insurance broker fees	41
Insurance broker organization code?	3
Insurance broker name	DEE W SLATER

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00062676

Policy instance

Insurance contract or identification number	00062676
Number of Individuals Covered	316
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4024931

Policy instance

Insurance contract or identification number	E4024931
Number of Individuals Covered	169
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $1,575
Total amount of fees paid to insurance company	USD $4,042
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $74
Amount paid for insurance broker fees	2875
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY INC

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ND250

Policy instance

Insurance contract or identification number	ND250
Number of Individuals Covered	221
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-01
Total amount of commissions paid to insurance broker	USD $18,079
Total amount of fees paid to insurance company	USD $287
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,987
Amount paid for insurance broker fees	55
Insurance broker organization code?	3
Insurance broker name	APRIL D MENARD

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00296057

Policy instance

Insurance contract or identification number	00296057
Number of Individuals Covered	570
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $16,188
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $301,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,188
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY INS.

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E4024931

Policy instance

Insurance contract or identification number	E4024931
Number of Individuals Covered	169
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $14,723
Total amount of fees paid to insurance company	USD $2,759
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,643
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,466
Amount paid for insurance broker fees	457
Insurance broker organization code?	3
Insurance broker name	LINDSAY DALFONSO

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00923708

Policy instance

Insurance contract or identification number	00923708
Number of Individuals Covered	555
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,365
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,365
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY INSURANCE

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00296057

Policy instance

Insurance contract or identification number	00296057
Number of Individuals Covered	550
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $15,421
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $307,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,400
Insurance broker organization code?	3
Insurance broker name	GERALD DE SOUZA

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E4024931

Policy instance

Insurance contract or identification number	E4024931
Number of Individuals Covered	165
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $2,877
Total amount of fees paid to insurance company	USD $8,158
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,068
Amount paid for insurance broker fees	6628
Insurance broker organization code?	3
Insurance broker name	JACQUELINE JACKSON

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E4024931

Policy instance

Insurance contract or identification number	E4024931
Number of Individuals Covered	165
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $27,344
Total amount of fees paid to insurance company	USD $6,684
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,398
Amount paid for insurance broker fees	4006
Insurance broker organization code?	3
Insurance broker name	LINDSAY DALFONSO

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00062676

Policy instance

Insurance contract or identification number	00062676
Number of Individuals Covered	317
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY, INC.

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ND250

Policy instance

Insurance contract or identification number	ND250
Number of Individuals Covered	176
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $19,555
Total amount of fees paid to insurance company	USD $1,475
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,783
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,477
Amount paid for insurance broker fees	392
Insurance broker organization code?	3
Insurance broker name	GAIL R BERGER

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

FJ274

Policy instance

Insurance contract or identification number	FJ274
Number of Individuals Covered	44
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,608
Total amount of fees paid to insurance company	USD $188
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $736
Insurance broker organization code?	3
Amount paid for insurance broker fees	85
Insurance broker name	SUSAN C BRIMHALL

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00062676

Policy instance

Insurance contract or identification number	00062676
Number of Individuals Covered	321
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $202,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

FJ274

Policy instance

Insurance contract or identification number	FJ274
Number of Individuals Covered	20
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,638
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,776
Insurance broker organization code?	3
Insurance broker name	THOMAS G HUNT

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ND250

Policy instance

Insurance contract or identification number	ND250
Number of Individuals Covered	155
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $26,840
Total amount of fees paid to insurance company	USD $24
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $118,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,989
Amount paid for insurance broker fees	13
Insurance broker organization code?	3
Insurance broker name	KELLY A IRVINE

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00296057

Policy instance

Insurance contract or identification number	00296057
Number of Individuals Covered	545
Insurance policy start date	2013-06-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $10,740
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $185,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,715
Insurance broker organization code?	3
Insurance broker name	GERALD DE SOUZA

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ND250

Policy instance

Insurance contract or identification number	ND250
Number of Individuals Covered	143
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $22,509
Total amount of fees paid to insurance company	USD $983
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $109,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2
Insurance broker organization code?	3
Amount paid for insurance broker fees	123
Insurance broker name	JEFFERY KOWALSKY

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00296057

Policy instance

Insurance contract or identification number	00296057
Number of Individuals Covered	534
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $9,702
Total amount of fees paid to insurance company	USD $3,033
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $262,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,702
Amount paid for insurance broker fees	3033
Insurance broker organization code?	3
Insurance broker name	GILROY KERNAN & GILROY INS.

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00296057

Policy instance

Insurance contract or identification number	00296057
Number of Individuals Covered	244
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $2,250
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ND250

Policy instance

Insurance contract or identification number	ND250
Number of Individuals Covered	133
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $17,677
Total amount of fees paid to insurance company	USD $804
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $94,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TMO5713135

Policy instance

Insurance contract or identification number	TMO5713135
Number of Individuals Covered	528
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $4,410
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $157,396
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

FJ274

Policy instance

Insurance contract or identification number	FJ274
Number of Individuals Covered	28
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,834
Total amount of fees paid to insurance company	USD $95
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

401623

Policy instance

Insurance contract or identification number	401623
Number of Individuals Covered	294
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00296057

Policy instance

Insurance contract or identification number	00296057
Number of Individuals Covered	232
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $2,187
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43
Insurance broker organization code?	3
Insurance broker name	AFS AGENCY

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ND250

Policy instance

Insurance contract or identification number	ND250
Number of Individuals Covered	126
Insurance policy start date	2009-10-01
Insurance policy end date	2010-09-30
Total amount of commissions paid to insurance broker	USD $16,932
Total amount of fees paid to insurance company	USD $549
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $92,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5
Insurance broker organization code?	3
Amount paid for insurance broker fees	38
Insurance broker name	JEFFERY KOWALSKY

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TMO5713135

Policy instance

Insurance contract or identification number	TMO5713135
Number of Individuals Covered	529
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,295
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $150,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,295
Insurance broker organization code?	3
Insurance broker name	STAFFWORKS LLC

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

FJ274

Policy instance

Insurance contract or identification number	FJ274
Number of Individuals Covered	22
Insurance policy start date	2009-05-01
Insurance policy end date	2010-04-30
Total amount of commissions paid to insurance broker	USD $2,596
Total amount of fees paid to insurance company	USD $98
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3
Insurance broker organization code?	3
Amount paid for insurance broker fees	6
Insurance broker name	SANDRA BECHTEL

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

378

Policy instance

Insurance contract or identification number	378
Number of Individuals Covered	549
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CARBONE MANAGEMENT GROUP, LLC
Employer identification number (EIN):	300028210
NAIC Classification:	441110
NAIC Description:	New Car Dealers

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	2001-11-06
Company Identification Number:	2696663
Legal Registered Office Address:	5700 HORATIO STREET Oneida UTICA United States of America (USA) 13502