| Plan Name | PRICESMART, INC. WELFARE BENEFIT PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
|
| Company Name: | PRICESMART, INC. |
| Employer identification number (EIN): | 330628530 |
| NAIC Classification: | 424400 |
Additional information about PRICESMART, INC.
| Jurisdiction of Incorporation: | Vermont Secretary of State Corporations Division |
| Incorporation Date: | 1994-09-23 |
| Company Identification Number: | 65308 |
| Legal Registered Office Address: |
400 CORNERSTONE DR #240 WILLISTON United States of America (USA) 05495 |
More information about PRICESMART, INC.
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2022-10-01 | TERRANCE MAHON | 2024-04-22 | ||
| 501 | 2021-10-01 | MARLENE RAMIREZ | 2023-02-13 | ||
| 501 | 2020-10-01 | ANDRES ORTIZ | 2022-04-05 | ||
| 501 | 2019-10-01 | ALBERTO J. MORALES | 2021-07-02 | ||
| 501 | 2019-09-01 | GRACE THOMAS | 2020-06-15 | ||
| 501 | 2018-09-01 | GRACE THOMAS | 2020-06-26 | ||
| 501 | 2017-09-01 | MARK G. RUDDY-HANBERG | 2019-04-15 | ||
| 501 | 2016-09-01 | ||||
| 501 | 2015-09-01 | MARK G RUDDY | |||
| 501 | 2014-09-01 | MARK G. RUDDY | |||
| 501 | 2013-09-01 | MARK RUDDY | |||
| 501 | 2012-10-01 | MARK RUDDY | |||
| 501 | 2011-10-01 | MARK RUDDY | |||
| 501 | 2009-10-01 | MARK RUDDY |
| 2022: PRICESMART, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses | ||
|---|---|---|
| 2022-10-01 | Type of plan entity | Single employer plan |
| 2022-10-01 | Plan funding arrangement – Insurance | Yes |
| 2022-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: PRICESMART, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses | ||
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: PRICESMART, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses | ||
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: PRICESMART, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses | ||
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019-09-01 | Type of plan entity | Single employer plan |
| 2019-09-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2019-09-01 | Plan funding arrangement – Insurance | Yes |
| 2019-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: PRICESMART, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses | ||
| 2018-09-01 | Type of plan entity | Single employer plan |
| 2018-09-01 | Plan funding arrangement – Insurance | Yes |
| 2018-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: PRICESMART, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses | ||
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: PRICESMART, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses | ||
| 2016-09-01 | Type of plan entity | Single employer plan |
| 2016-09-01 | Submission has been amended | No |
| 2016-09-01 | This submission is the final filing | No |
| 2016-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-09-01 | Plan is a collectively bargained plan | No |
| 2016-09-01 | Plan funding arrangement – Insurance | Yes |
| 2016-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: PRICESMART, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses | ||
| 2015-09-01 | Type of plan entity | Single employer plan |
| 2015-09-01 | Submission has been amended | No |
| 2015-09-01 | This submission is the final filing | No |
| 2015-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-09-01 | Plan is a collectively bargained plan | No |
| 2015-09-01 | Plan funding arrangement – Insurance | Yes |
| 2015-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: PRICESMART, INC. WELFARE BENEFIT PLAN 2014 form 5500 responses | ||
| 2014-09-01 | Type of plan entity | Single employer plan |
| 2014-09-01 | Submission has been amended | No |
| 2014-09-01 | This submission is the final filing | No |
| 2014-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-09-01 | Plan is a collectively bargained plan | No |
| 2014-09-01 | Plan funding arrangement – Insurance | Yes |
| 2014-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: PRICESMART, INC. WELFARE BENEFIT PLAN 2013 form 5500 responses | ||
| 2013-09-01 | Type of plan entity | Single employer plan |
| 2013-09-01 | Submission has been amended | No |
| 2013-09-01 | This submission is the final filing | No |
| 2013-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-09-01 | Plan is a collectively bargained plan | No |
| 2013-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: PRICESMART, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses | ||
| 2012-10-01 | Type of plan entity | Single employer plan |
| 2012-10-01 | Submission has been amended | No |
| 2012-10-01 | This submission is the final filing | No |
| 2012-10-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2012-10-01 | Plan is a collectively bargained plan | No |
| 2012-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: PRICESMART, INC. WELFARE BENEFIT PLAN 2011 form 5500 responses | ||
| 2011-10-01 | Type of plan entity | Single employer plan |
| 2011-10-01 | Submission has been amended | No |
| 2011-10-01 | This submission is the final filing | No |
| 2011-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-10-01 | Plan is a collectively bargained plan | No |
| 2011-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: PRICESMART, INC. WELFARE BENEFIT PLAN 2009 form 5500 responses | ||
| 2009-10-01 | Type of plan entity | Single employer plan |
| 2009-10-01 | Submission has been amended | No |
| 2009-10-01 | This submission is the final filing | No |
| 2009-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-10-01 | Plan is a collectively bargained plan | No |
| 2009-10-01 | Plan funding arrangement – Insurance | Yes |
| 2009-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) | |
| Policy contract number | ADDN04156031 |
| Policy instance | 2 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 143739 |
| Policy instance | 6 |
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 66169 |
| Policy instance | 5 |
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 541281 |
| Policy instance | 4 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 143739HNO |
| Policy instance | 3 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) | |
| Policy contract number | 919405 |
| Policy instance | 7 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 1 |
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | N04156031 |
| Policy instance | 2 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) | |
| Policy contract number | 804021G |
| Policy instance | 3 |
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) | |
| Policy contract number | PJ307 |
| Policy instance | 4 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 143739HNO |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 143739 |
| Policy instance | 6 |
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) | |
| Policy contract number | N04156031 |
| Policy instance | 2 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) | |
| Policy contract number | 804021G |
| Policy instance | 3 |
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) | |
| Policy contract number | PJ307 |
| Policy instance | 4 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 143739HNO |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 143739 |
| Policy instance | 6 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 1 |
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) | |
| Policy contract number | N04156031 |
| Policy instance | 2 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) | |
| Policy contract number | 804021G |
| Policy instance | 3 |
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) | |
| Policy contract number | PJ307 |
| Policy instance | 4 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 143739HNO |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 143739 |
| Policy instance | 6 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) | |
| Policy contract number | 3341124 |
| Policy instance | 1 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) | |
| Policy contract number | 804021G |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 887473-01000001 |
| Policy instance | 5 |
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) | |
| Policy contract number | PJ307 |
| Policy instance | 6 |
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) | |
| Policy contract number | ADDN04156031 |
| Policy instance | 3 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 2 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) | |
| Policy contract number | 3341124 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 2 |
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) | |
| Policy contract number | ADDN04156031 |
| Policy instance | 3 |
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) | |
| Policy contract number | PJ307 |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 5 |
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) | |
| Policy contract number | ADDN04156031 |
| Policy instance | 3 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 2 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) | |
| Policy contract number | 3341124 |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 0654967 |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 0654967 |
| Policy instance | 5 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 654967HNO |
| Policy instance | 4 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 3 |
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 66169/541281 |
| Policy instance | 2 |
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) | |
| Policy contract number | ADDN04156031 |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 4 |
| FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 ) | |
| Policy contract number | 4EL-7460-14 |
| Policy instance | 3 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | US328036 |
| Policy instance | 2 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 1 |
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 6 |
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) | |
| Policy contract number | ADDN04156031 |
| Policy instance | 5 |
| FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 ) | |
| Policy contract number | 4EL-7460-13 |
| Policy instance | 1 |
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 2 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 3 |
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) | |
| Policy contract number | GTP9120196 |
| Policy instance | 4 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | US328036 |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 6 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | US328036 |
| Policy instance | 7 |
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) | |
| Policy contract number | 593140 |
| Policy instance | 8 |
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 6 |
| FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 ) | |
| Policy contract number | 4EL-7460-13 |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 3 |
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) | |
| Policy contract number | GTP9120196 |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 469442-54-020 |
| Policy instance | 2 |
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 7 |
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) | |
| Policy contract number | GTP9120196 |
| Policy instance | 6 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 469442-54-020 |
| Policy instance | 5 |
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) | |
| Policy contract number | 593140 |
| Policy instance | 4 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | US328036 |
| Policy instance | 3 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 2 |
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 2 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 118457 |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 95484 ) | |
| Policy contract number | US328036 |
| Policy instance | 4 |
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) | |
| Policy contract number | GTP9120196 |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 654967 |
| Policy instance | 6 |
| AETNA GLOBAL BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 299804-052-0002 |
| Policy instance | 3 |