NISOURCE INC. has sponsored the creation of one or more 401k plans.
Additional information about NISOURCE INC.
Submission information for form 5500 for 401k plan NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM
| Measure | Date | Value |
|---|
| 2022 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2022 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2022-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-12-31 | $13,442,133 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-12-31 | $15,967,223 |
| Total income from all sources (including contributions) | 2022-12-31 | $98,644,647 |
| Total loss/gain on sale of assets | 2022-12-31 | $0 |
| Total of all expenses incurred | 2022-12-31 | $127,352,183 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-12-31 | $122,509,201 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-12-31 | $118,934,313 |
| Value of total assets at end of year | 2022-12-31 | $138,199,364 |
| Value of total assets at beginning of year | 2022-12-31 | $169,431,990 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2022-12-31 | $4,842,982 |
| Total interest from all sources | 2022-12-31 | $-136 |
| Total dividends received (eg from common stock, registered investment company shares) | 2022-12-31 | $1,803,714 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2022-12-31 | $1,803,714 |
| Administrative expenses professional fees incurred | 2022-12-31 | $339,248 |
| Was this plan covered by a fidelity bond | 2022-12-31 | Yes |
| Value of fidelity bond cover | 2022-12-31 | $50,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2022-12-31 | No |
| Contributions received from participants | 2022-12-31 | $29,381,019 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2022-12-31 | $8,765 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2022-12-31 | $10,096,847 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2022-12-31 | $7,120,774 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2022-12-31 | $41,260 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2022-12-31 | $114,075 |
| Other income not declared elsewhere | 2022-12-31 | $2,249,500 |
| Administrative expenses (other) incurred | 2022-12-31 | $41,293 |
| Liabilities. Value of operating payables at end of year | 2022-12-31 | $1,200,873 |
| Liabilities. Value of operating payables at beginning of year | 2022-12-31 | $2,653,148 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Value of net income/loss | 2022-12-31 | $-28,707,536 |
| Value of net assets at end of year (total assets less liabilities) | 2022-12-31 | $124,757,231 |
| Value of net assets at beginning of year (total assets less liabilities) | 2022-12-31 | $153,464,767 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2022-12-31 | $85,846,285 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2022-12-31 | $110,698,061 |
| Value of interest in master investment trust accounts at end of year | 2022-12-31 | $16,893,275 |
| Value of interest in master investment trust accounts at beginning of year | 2022-12-31 | $21,707,290 |
| Value of interest in common/collective trusts at end of year | 2022-12-31 | $16,054,244 |
| Value of interest in common/collective trusts at beginning of year | 2022-12-31 | $20,423,208 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2022-12-31 | $-136 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2022-12-31 | $10,665,897 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2022-12-31 | $-15,803,686 |
| Net investment gain or loss from common/collective trusts | 2022-12-31 | $-3,551,098 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2022-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-12-31 | No |
| Contributions received in cash from employer | 2022-12-31 | $89,553,294 |
| Employer contributions (assets) at end of year | 2022-12-31 | $9,308,713 |
| Employer contributions (assets) at beginning of year | 2022-12-31 | $9,482,657 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2022-12-31 | $111,834,539 |
| Contract administrator fees | 2022-12-31 | $4,462,441 |
| Liabilities. Value of benefit claims payable at end of year | 2022-12-31 | $12,200,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2022-12-31 | $13,200,000 |
| Did the plan have assets held for investment | 2022-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2022-12-31 | Unqualified |
| Accountancy firm name | 2022-12-31 | MCCONNELL & JONES LLP |
| Accountancy firm EIN | 2022-12-31 | 760488832 |
| 2021 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2021 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2021-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $15,967,223 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $15,148,089 |
| Total income from all sources (including contributions) | 2021-12-31 | $134,910,387 |
| Total loss/gain on sale of assets | 2021-12-31 | $0 |
| Total of all expenses incurred | 2021-12-31 | $129,835,321 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-12-31 | $125,235,018 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-12-31 | $117,438,769 |
| Value of total assets at end of year | 2021-12-31 | $169,431,990 |
| Value of total assets at beginning of year | 2021-12-31 | $163,537,790 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-12-31 | $4,600,303 |
| Total interest from all sources | 2021-12-31 | $-217 |
| Total dividends received (eg from common stock, registered investment company shares) | 2021-12-31 | $1,903,989 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2021-12-31 | $1,903,989 |
| Administrative expenses professional fees incurred | 2021-12-31 | $208,699 |
| Was this plan covered by a fidelity bond | 2021-12-31 | Yes |
| Value of fidelity bond cover | 2021-12-31 | $50,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2021-12-31 | No |
| Contributions received from participants | 2021-12-31 | $27,416,833 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2021-12-31 | $2,143,905 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2021-12-31 | $7,120,774 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2021-12-31 | $5,275,528 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2021-12-31 | $114,075 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2021-12-31 | $171,531 |
| Other income not declared elsewhere | 2021-12-31 | $1,856,591 |
| Administrative expenses (other) incurred | 2021-12-31 | $39,317 |
| Liabilities. Value of operating payables at end of year | 2021-12-31 | $2,653,148 |
| Liabilities. Value of operating payables at beginning of year | 2021-12-31 | $1,476,558 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Value of net income/loss | 2021-12-31 | $5,075,066 |
| Value of net assets at end of year (total assets less liabilities) | 2021-12-31 | $153,464,767 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-12-31 | $148,389,701 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2021-12-31 | $110,698,061 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2021-12-31 | $112,171,262 |
| Value of interest in master investment trust accounts at end of year | 2021-12-31 | $21,707,290 |
| Value of interest in master investment trust accounts at beginning of year | 2021-12-31 | $27,240,789 |
| Value of interest in common/collective trusts at end of year | 2021-12-31 | $20,423,208 |
| Value of interest in common/collective trusts at beginning of year | 2021-12-31 | $18,850,211 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2021-12-31 | $-217 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-12-31 | $12,146,142 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2021-12-31 | $7,279,201 |
| Net investment gain or loss from common/collective trusts | 2021-12-31 | $2,482,896 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2021-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-12-31 | No |
| Contributions received in cash from employer | 2021-12-31 | $90,021,936 |
| Employer contributions (assets) at end of year | 2021-12-31 | $9,482,657 |
| Employer contributions (assets) at beginning of year | 2021-12-31 | $0 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-12-31 | $110,944,971 |
| Contract administrator fees | 2021-12-31 | $4,352,287 |
| Liabilities. Value of benefit claims payable at end of year | 2021-12-31 | $13,200,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2021-12-31 | $13,500,000 |
| Did the plan have assets held for investment | 2021-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2021-12-31 | Unqualified |
| Accountancy firm name | 2021-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2021-12-31 | 133891517 |
| 2020 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2020 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2020-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $15,148,089 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $16,269,313 |
| Total income from all sources (including contributions) | 2020-12-31 | $139,854,935 |
| Total loss/gain on sale of assets | 2020-12-31 | $0 |
| Total of all expenses incurred | 2020-12-31 | $125,171,708 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-12-31 | $120,431,213 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-12-31 | $118,644,894 |
| Value of total assets at end of year | 2020-12-31 | $163,537,790 |
| Value of total assets at beginning of year | 2020-12-31 | $149,975,787 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-12-31 | $4,740,495 |
| Total interest from all sources | 2020-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2020-12-31 | $1,940,493 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2020-12-31 | $1,940,493 |
| Administrative expenses professional fees incurred | 2020-12-31 | $225,368 |
| Was this plan covered by a fidelity bond | 2020-12-31 | Yes |
| Value of fidelity bond cover | 2020-12-31 | $50,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2020-12-31 | No |
| Contributions received from participants | 2020-12-31 | $27,609,679 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2020-12-31 | $1,502,643 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2020-12-31 | $5,275,528 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2020-12-31 | $2,810,772 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2020-12-31 | $171,531 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2020-12-31 | $189,418 |
| Other income not declared elsewhere | 2020-12-31 | $2,317,610 |
| Administrative expenses (other) incurred | 2020-12-31 | $40,300 |
| Liabilities. Value of operating payables at end of year | 2020-12-31 | $1,476,558 |
| Liabilities. Value of operating payables at beginning of year | 2020-12-31 | $1,479,895 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Value of net income/loss | 2020-12-31 | $14,683,227 |
| Value of net assets at end of year (total assets less liabilities) | 2020-12-31 | $148,389,701 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-12-31 | $133,706,474 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2020-12-31 | $112,171,262 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2020-12-31 | $105,941,012 |
| Value of interest in master investment trust accounts at end of year | 2020-12-31 | $27,240,789 |
| Value of interest in master investment trust accounts at beginning of year | 2020-12-31 | $24,195,472 |
| Value of interest in common/collective trusts at end of year | 2020-12-31 | $18,850,211 |
| Value of interest in common/collective trusts at beginning of year | 2020-12-31 | $13,838,631 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2020-12-31 | $0 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2020-12-31 | $3,189,900 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2020-12-31 | $3,189,900 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-12-31 | $17,610,190 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2020-12-31 | $11,230,931 |
| Net investment gain or loss from common/collective trusts | 2020-12-31 | $2,675,690 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2020-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-12-31 | No |
| Contributions received in cash from employer | 2020-12-31 | $91,035,215 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2020-12-31 | $101,318,380 |
| Contract administrator fees | 2020-12-31 | $4,474,827 |
| Liabilities. Value of benefit claims payable at end of year | 2020-12-31 | $13,500,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2020-12-31 | $14,600,000 |
| Did the plan have assets held for investment | 2020-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2020-12-31 | Disclaimer |
| Accountancy firm name | 2020-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2020-12-31 | 133891517 |
| 2019 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2019 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2019-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $16,269,313 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $14,541,029 |
| Total income from all sources (including contributions) | 2019-12-31 | $147,040,569 |
| Total loss/gain on sale of assets | 2019-12-31 | $0 |
| Total of all expenses incurred | 2019-12-31 | $133,301,472 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $128,584,244 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $124,838,281 |
| Value of total assets at end of year | 2019-12-31 | $149,975,787 |
| Value of total assets at beginning of year | 2019-12-31 | $134,508,406 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $4,717,228 |
| Total interest from all sources | 2019-12-31 | $-70 |
| Total dividends received (eg from common stock, registered investment company shares) | 2019-12-31 | $2,246,991 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2019-12-31 | $2,246,991 |
| Administrative expenses professional fees incurred | 2019-12-31 | $255,942 |
| Was this plan covered by a fidelity bond | 2019-12-31 | Yes |
| Value of fidelity bond cover | 2019-12-31 | $50,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Contributions received from participants | 2019-12-31 | $26,058,687 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2019-12-31 | $1,010,804 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-12-31 | $2,810,772 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2019-12-31 | $2,322,623 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2019-12-31 | $189,418 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2019-12-31 | $203,603 |
| Other income not declared elsewhere | 2019-12-31 | $1,018,257 |
| Administrative expenses (other) incurred | 2019-12-31 | $37,678 |
| Liabilities. Value of operating payables at end of year | 2019-12-31 | $1,479,895 |
| Liabilities. Value of operating payables at beginning of year | 2019-12-31 | $1,037,426 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Value of net income/loss | 2019-12-31 | $13,739,097 |
| Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $133,706,474 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $119,967,377 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2019-12-31 | $105,941,012 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2019-12-31 | $98,406,652 |
| Value of interest in master investment trust accounts at end of year | 2019-12-31 | $24,195,472 |
| Value of interest in master investment trust accounts at beginning of year | 2019-12-31 | $20,239,338 |
| Value of interest in common/collective trusts at end of year | 2019-12-31 | $13,838,631 |
| Value of interest in common/collective trusts at beginning of year | 2019-12-31 | $11,294,524 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2019-12-31 | $3,189,900 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2019-12-31 | $2,245,269 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2019-12-31 | $2,245,269 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2019-12-31 | $-70 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $18,243,043 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2019-12-31 | $11,843,353 |
| Net investment gain or loss from common/collective trusts | 2019-12-31 | $3,100,354 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Contributions received in cash from employer | 2019-12-31 | $98,779,594 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2019-12-31 | $109,330,397 |
| Contract administrator fees | 2019-12-31 | $4,423,608 |
| Liabilities. Value of benefit claims payable at end of year | 2019-12-31 | $14,600,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2019-12-31 | $13,300,000 |
| Did the plan have assets held for investment | 2019-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2019-12-31 | Disclaimer |
| Accountancy firm name | 2019-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2019-12-31 | 133891517 |
| 2018 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2018 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2018-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $14,541,029 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $12,729,517 |
| Total income from all sources (including contributions) | 2018-12-31 | $111,390,934 |
| Total loss/gain on sale of assets | 2018-12-31 | $0 |
| Total of all expenses incurred | 2018-12-31 | $126,458,457 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-12-31 | $124,801,647 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-12-31 | $115,577,859 |
| Value of total assets at end of year | 2018-12-31 | $134,508,406 |
| Value of total assets at beginning of year | 2018-12-31 | $147,764,417 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-12-31 | $1,656,810 |
| Total interest from all sources | 2018-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2018-12-31 | $2,243,435 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2018-12-31 | $2,243,435 |
| Administrative expenses professional fees incurred | 2018-12-31 | $253,291 |
| Was this plan covered by a fidelity bond | 2018-12-31 | Yes |
| Value of fidelity bond cover | 2018-12-31 | $50,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2018-12-31 | No |
| Contributions received from participants | 2018-12-31 | $25,100,237 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2018-12-31 | $995,214 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2018-12-31 | $2,322,623 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2018-12-31 | $1,194,537 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2018-12-31 | $203,603 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2018-12-31 | $183,674 |
| Other income not declared elsewhere | 2018-12-31 | $792,018 |
| Administrative expenses (other) incurred | 2018-12-31 | $36,556 |
| Liabilities. Value of operating payables at end of year | 2018-12-31 | $1,037,426 |
| Liabilities. Value of operating payables at beginning of year | 2018-12-31 | $1,845,843 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Value of net income/loss | 2018-12-31 | $-15,067,523 |
| Value of net assets at end of year (total assets less liabilities) | 2018-12-31 | $119,967,377 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-12-31 | $135,034,900 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2018-12-31 | $98,406,652 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2018-12-31 | $117,074,412 |
| Value of interest in master investment trust accounts at end of year | 2018-12-31 | $20,239,338 |
| Value of interest in master investment trust accounts at beginning of year | 2018-12-31 | $20,501,211 |
| Value of interest in common/collective trusts at end of year | 2018-12-31 | $11,294,524 |
| Value of interest in common/collective trusts at beginning of year | 2018-12-31 | $5,318,343 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2018-12-31 | $2,245,269 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2018-12-31 | $3,675,914 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2018-12-31 | $3,675,914 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2018-12-31 | $17,456,946 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2018-12-31 | $-6,567,324 |
| Net investment gain or loss from common/collective trusts | 2018-12-31 | $-79,157 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2018-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-12-31 | No |
| Contributions received in cash from employer | 2018-12-31 | $90,477,622 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2018-12-31 | $106,349,487 |
| Contract administrator fees | 2018-12-31 | $1,366,963 |
| Liabilities. Value of benefit claims payable at end of year | 2018-12-31 | $13,300,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2018-12-31 | $10,700,000 |
| Did the plan have assets held for investment | 2018-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2018-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2018-12-31 | Disclaimer |
| Accountancy firm name | 2018-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2018-12-31 | 133891517 |
| 2017 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2017 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2017-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $12,729,517 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $15,684,889 |
| Total income from all sources (including contributions) | 2017-12-31 | $144,134,541 |
| Total loss/gain on sale of assets | 2017-12-31 | $0 |
| Total of all expenses incurred | 2017-12-31 | $128,777,476 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-12-31 | $125,097,574 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-12-31 | $125,333,495 |
| Value of total assets at end of year | 2017-12-31 | $147,764,417 |
| Value of total assets at beginning of year | 2017-12-31 | $135,362,724 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-12-31 | $3,679,902 |
| Total interest from all sources | 2017-12-31 | $-62 |
| Total dividends received (eg from common stock, registered investment company shares) | 2017-12-31 | $1,787,343 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2017-12-31 | $1,787,343 |
| Administrative expenses professional fees incurred | 2017-12-31 | $282,487 |
| Was this plan covered by a fidelity bond | 2017-12-31 | Yes |
| Value of fidelity bond cover | 2017-12-31 | $50,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2017-12-31 | Yes |
| Amount of non-exempt transactions with any party-in-interest | 2017-12-31 | $82,000 |
| Contributions received from participants | 2017-12-31 | $23,016,510 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2017-12-31 | $1,606,735 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2017-12-31 | $1,194,537 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2017-12-31 | $1,447,227 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2017-12-31 | $183,674 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2017-12-31 | $2,691,735 |
| Administrative expenses (other) incurred | 2017-12-31 | $35,582 |
| Liabilities. Value of operating payables at end of year | 2017-12-31 | $1,845,843 |
| Liabilities. Value of operating payables at beginning of year | 2017-12-31 | $1,393,154 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Value of net income/loss | 2017-12-31 | $15,357,065 |
| Value of net assets at end of year (total assets less liabilities) | 2017-12-31 | $135,034,900 |
| Value of net assets at beginning of year (total assets less liabilities) | 2017-12-31 | $119,677,835 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2017-12-31 | $117,074,412 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2017-12-31 | $103,906,394 |
| Value of interest in master investment trust accounts at end of year | 2017-12-31 | $20,501,211 |
| Value of interest in master investment trust accounts at beginning of year | 2017-12-31 | $17,875,308 |
| Value of interest in common/collective trusts at end of year | 2017-12-31 | $5,318,343 |
| Value of interest in common/collective trusts at beginning of year | 2017-12-31 | $6,481,612 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2017-12-31 | $3,675,914 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2017-12-31 | $5,652,183 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2017-12-31 | $5,652,183 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2017-12-31 | $-62 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-12-31 | $16,972,398 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2017-12-31 | $13,234,066 |
| Net investment gain or loss from common/collective trusts | 2017-12-31 | $1,259,593 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2017-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-12-31 | No |
| Contributions received in cash from employer | 2017-12-31 | $102,316,985 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2017-12-31 | $106,518,441 |
| Contract administrator fees | 2017-12-31 | $3,361,833 |
| Liabilities. Value of benefit claims payable at end of year | 2017-12-31 | $10,700,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2017-12-31 | $11,600,000 |
| Did the plan have assets held for investment | 2017-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2017-12-31 | Disclaimer |
| Accountancy firm name | 2017-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2017-12-31 | 133891517 |
| 2016 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2016 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2016-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $15,684,889 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $15,494,241 |
| Total income from all sources (including contributions) | 2016-12-31 | $119,624,076 |
| Total loss/gain on sale of assets | 2016-12-31 | $0 |
| Total of all expenses incurred | 2016-12-31 | $117,870,614 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-12-31 | $114,107,582 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-12-31 | $110,800,006 |
| Value of total assets at end of year | 2016-12-31 | $135,362,724 |
| Value of total assets at beginning of year | 2016-12-31 | $133,418,614 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-12-31 | $3,763,032 |
| Total interest from all sources | 2016-12-31 | $-348 |
| Total dividends received (eg from common stock, registered investment company shares) | 2016-12-31 | $1,705,060 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2016-12-31 | $1,705,060 |
| Administrative expenses professional fees incurred | 2016-12-31 | $199,283 |
| Was this plan covered by a fidelity bond | 2016-12-31 | Yes |
| Value of fidelity bond cover | 2016-12-31 | $50,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2016-12-31 | No |
| Amount of non-exempt transactions with any party-in-interest | 2016-12-31 | $444,000 |
| Contributions received from participants | 2016-12-31 | $21,352,654 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2016-12-31 | $467,891 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2016-12-31 | $1,447,227 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2016-12-31 | $942,793 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2016-12-31 | $2,691,735 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2016-12-31 | $1,098,833 |
| Administrative expenses (other) incurred | 2016-12-31 | $417,170 |
| Liabilities. Value of operating payables at end of year | 2016-12-31 | $1,393,154 |
| Liabilities. Value of operating payables at beginning of year | 2016-12-31 | $1,295,408 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Value of net income/loss | 2016-12-31 | $1,753,462 |
| Value of net assets at end of year (total assets less liabilities) | 2016-12-31 | $119,677,835 |
| Value of net assets at beginning of year (total assets less liabilities) | 2016-12-31 | $117,924,373 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2016-12-31 | $103,906,394 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2016-12-31 | $103,655,589 |
| Value of interest in master investment trust accounts at end of year | 2016-12-31 | $17,875,308 |
| Value of interest in master investment trust accounts at beginning of year | 2016-12-31 | $20,925,700 |
| Value of interest in common/collective trusts at end of year | 2016-12-31 | $6,481,612 |
| Value of interest in common/collective trusts at beginning of year | 2016-12-31 | $7,177,981 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2016-12-31 | $5,652,183 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2016-12-31 | $716,551 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2016-12-31 | $716,551 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2016-12-31 | $-348 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-12-31 | $14,724,209 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2016-12-31 | $4,856,243 |
| Net investment gain or loss from common/collective trusts | 2016-12-31 | $787,502 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2016-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-12-31 | No |
| Contributions received in cash from employer | 2016-12-31 | $89,447,352 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2016-12-31 | $98,915,482 |
| Contract administrator fees | 2016-12-31 | $3,146,579 |
| Liabilities. Value of benefit claims payable at end of year | 2016-12-31 | $11,600,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2016-12-31 | $13,100,000 |
| Did the plan have assets held for investment | 2016-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2016-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2016-12-31 | Disclaimer |
| Accountancy firm name | 2016-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2016-12-31 | 133891517 |
| 2015 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2015 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2015-12-31 | $0 |
| Total transfer of assets to this plan | 2015-12-31 | $511,204 |
| Total transfer of assets from this plan | 2015-12-31 | $110,570,484 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $15,494,241 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $17,797,582 |
| Total income from all sources (including contributions) | 2015-12-31 | $113,641,666 |
| Total loss/gain on sale of assets | 2015-12-31 | $0 |
| Total of all expenses incurred | 2015-12-31 | $120,555,757 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-12-31 | $116,608,858 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-12-31 | $112,727,424 |
| Value of total assets at end of year | 2015-12-31 | $133,418,614 |
| Value of total assets at beginning of year | 2015-12-31 | $252,695,326 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-12-31 | $3,946,899 |
| Total interest from all sources | 2015-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2015-12-31 | $2,450,708 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2015-12-31 | $2,450,708 |
| Administrative expenses professional fees incurred | 2015-12-31 | $157,461 |
| Was this plan covered by a fidelity bond | 2015-12-31 | Yes |
| Value of fidelity bond cover | 2015-12-31 | $50,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2015-12-31 | No |
| Contributions received from participants | 2015-12-31 | $22,829,068 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2015-12-31 | $782,415 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2015-12-31 | $942,793 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2015-12-31 | $349,268 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2015-12-31 | $1,098,833 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2015-12-31 | $1,324,482 |
| Administrative expenses (other) incurred | 2015-12-31 | $755,188 |
| Liabilities. Value of operating payables at end of year | 2015-12-31 | $1,295,408 |
| Liabilities. Value of operating payables at beginning of year | 2015-12-31 | $1,973,100 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Value of net income/loss | 2015-12-31 | $-6,914,091 |
| Value of net assets at end of year (total assets less liabilities) | 2015-12-31 | $117,924,373 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-12-31 | $234,897,744 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2015-12-31 | $103,655,589 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2015-12-31 | $213,185,591 |
| Value of interest in master investment trust accounts at end of year | 2015-12-31 | $20,925,700 |
| Value of interest in master investment trust accounts at beginning of year | 2015-12-31 | $23,103,966 |
| Value of interest in common/collective trusts at end of year | 2015-12-31 | $7,177,981 |
| Value of interest in common/collective trusts at beginning of year | 2015-12-31 | $14,707,453 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2015-12-31 | $716,551 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2015-12-31 | $183,556 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2015-12-31 | $183,556 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-12-31 | $16,940,576 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2015-12-31 | $-1,906,776 |
| Net investment gain or loss from common/collective trusts | 2015-12-31 | $109,771 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2015-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-12-31 | No |
| Contributions received in cash from employer | 2015-12-31 | $89,898,356 |
| Employer contributions (assets) at end of year | 2015-12-31 | $0 |
| Employer contributions (assets) at beginning of year | 2015-12-31 | $1,165,492 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-12-31 | $98,885,867 |
| Contract administrator fees | 2015-12-31 | $3,034,250 |
| Liabilities. Value of benefit claims payable at end of year | 2015-12-31 | $13,100,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2015-12-31 | $14,500,000 |
| Did the plan have assets held for investment | 2015-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2015-12-31 | Disclaimer |
| Accountancy firm name | 2015-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2015-12-31 | 133891517 |
| 2014 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2014 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2014-12-31 | $0 |
| Total transfer of assets to this plan | 2014-12-31 | $253,325 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $17,797,582 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $13,995,375 |
| Total income from all sources (including contributions) | 2014-12-31 | $134,434,263 |
| Total loss/gain on sale of assets | 2014-12-31 | $0 |
| Total of all expenses incurred | 2014-12-31 | $131,693,717 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-12-31 | $126,327,479 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-12-31 | $120,746,316 |
| Value of total assets at end of year | 2014-12-31 | $252,695,326 |
| Value of total assets at beginning of year | 2014-12-31 | $245,899,248 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-12-31 | $5,366,238 |
| Total interest from all sources | 2014-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-12-31 | $3,124,819 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2014-12-31 | $3,124,819 |
| Administrative expenses professional fees incurred | 2014-12-31 | $193,282 |
| Was this plan covered by a fidelity bond | 2014-12-31 | Yes |
| Value of fidelity bond cover | 2014-12-31 | $50,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2014-12-31 | No |
| Contributions received from participants | 2014-12-31 | $25,233,223 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2014-12-31 | $39,683 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2014-12-31 | $349,268 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2014-12-31 | $49,288 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2014-12-31 | $1,324,482 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2014-12-31 | $49,253 |
| Other income not declared elsewhere | 2014-12-31 | $10,550 |
| Administrative expenses (other) incurred | 2014-12-31 | $1,164,892 |
| Liabilities. Value of operating payables at end of year | 2014-12-31 | $1,973,100 |
| Liabilities. Value of operating payables at beginning of year | 2014-12-31 | $3,646,122 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Value of net income/loss | 2014-12-31 | $2,740,546 |
| Value of net assets at end of year (total assets less liabilities) | 2014-12-31 | $234,897,744 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-12-31 | $231,903,873 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2014-12-31 | $213,185,591 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2014-12-31 | $59,641,154 |
| Value of interest in master investment trust accounts at end of year | 2014-12-31 | $23,103,966 |
| Value of interest in master investment trust accounts at beginning of year | 2014-12-31 | $180,679,255 |
| Value of interest in common/collective trusts at end of year | 2014-12-31 | $14,707,453 |
| Value of interest in common/collective trusts at beginning of year | 2014-12-31 | $4,237,480 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2014-12-31 | $183,556 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2014-12-31 | $324,854 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2014-12-31 | $324,854 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-12-31 | $18,946,737 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2014-12-31 | $6,608,507 |
| Net investment gain or loss from common/collective trusts | 2014-12-31 | $1,984,316 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2014-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-12-31 | No |
| Contributions received in cash from employer | 2014-12-31 | $95,513,093 |
| Employer contributions (assets) at end of year | 2014-12-31 | $1,165,492 |
| Employer contributions (assets) at beginning of year | 2014-12-31 | $967,217 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2014-12-31 | $107,341,059 |
| Contract administrator fees | 2014-12-31 | $4,008,064 |
| Liabilities. Value of benefit claims payable at end of year | 2014-12-31 | $14,500,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2014-12-31 | $10,300,000 |
| Did the plan have assets held for investment | 2014-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2014-12-31 | Disclaimer |
| Accountancy firm name | 2014-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2014-12-31 | 133891517 |
| 2013 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2013 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2013-12-31 | $39 |
| Total unrealized appreciation/depreciation of assets | 2013-12-31 | $39 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $13,995,375 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $11,775,571 |
| Total income from all sources (including contributions) | 2013-12-31 | $160,866,766 |
| Total loss/gain on sale of assets | 2013-12-31 | $0 |
| Total of all expenses incurred | 2013-12-31 | $126,448,785 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-12-31 | $122,025,791 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-12-31 | $123,637,782 |
| Value of total assets at end of year | 2013-12-31 | $245,899,248 |
| Value of total assets at beginning of year | 2013-12-31 | $209,261,463 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-12-31 | $4,422,994 |
| Total interest from all sources | 2013-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-12-31 | $915,114 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2013-12-31 | $915,114 |
| Administrative expenses professional fees incurred | 2013-12-31 | $180,700 |
| Was this plan covered by a fidelity bond | 2013-12-31 | Yes |
| Value of fidelity bond cover | 2013-12-31 | $50,000,000 |
| If this is an individual account plan, was there a blackout period | 2013-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-12-31 | No |
| Contributions received from participants | 2013-12-31 | $25,026,230 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2013-12-31 | $1,566,774 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2013-12-31 | $49,288 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2013-12-31 | $46,776 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2013-12-31 | $49,253 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2013-12-31 | $46,695 |
| Liabilities. Value of operating payables at end of year | 2013-12-31 | $3,646,122 |
| Liabilities. Value of operating payables at beginning of year | 2013-12-31 | $2,628,876 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Value of net income/loss | 2013-12-31 | $34,417,981 |
| Value of net assets at end of year (total assets less liabilities) | 2013-12-31 | $231,903,873 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-12-31 | $197,485,892 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2013-12-31 | $59,641,154 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2013-12-31 | $52,189,388 |
| Value of interest in master investment trust accounts at end of year | 2013-12-31 | $180,679,255 |
| Value of interest in master investment trust accounts at beginning of year | 2013-12-31 | $152,276,428 |
| Value of interest in common/collective trusts at end of year | 2013-12-31 | $4,237,480 |
| Value of interest in common/collective trusts at beginning of year | 2013-12-31 | $3,602,901 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2013-12-31 | $324,854 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2013-12-31 | $280,465 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2013-12-31 | $280,465 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-12-31 | $25,447,464 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2013-12-31 | $7,936,652 |
| Net investment gain or loss from common/collective trusts | 2013-12-31 | $1,085,077 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2013-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-12-31 | No |
| Contributions received in cash from employer | 2013-12-31 | $98,611,552 |
| Employer contributions (assets) at end of year | 2013-12-31 | $967,217 |
| Employer contributions (assets) at beginning of year | 2013-12-31 | $865,505 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-12-31 | $95,011,553 |
| Contract administrator fees | 2013-12-31 | $4,242,294 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2013-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2013-12-31 | $10,300,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2013-12-31 | $9,100,000 |
| Did the plan have assets held for investment | 2013-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2013-12-31 | Disclaimer |
| Accountancy firm name | 2013-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2013-12-31 | 133891517 |
| 2012 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2012 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2012-12-31 | $223 |
| Total unrealized appreciation/depreciation of assets | 2012-12-31 | $223 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $11,775,571 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $11,275,520 |
| Total income from all sources (including contributions) | 2012-12-31 | $141,044,245 |
| Total loss/gain on sale of assets | 2012-12-31 | $0 |
| Total of all expenses incurred | 2012-12-31 | $117,585,074 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-12-31 | $113,480,721 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-12-31 | $115,441,488 |
| Value of total assets at end of year | 2012-12-31 | $209,261,463 |
| Value of total assets at beginning of year | 2012-12-31 | $185,302,241 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-12-31 | $4,104,353 |
| Total interest from all sources | 2012-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2012-12-31 | $939,874 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2012-12-31 | $939,874 |
| Administrative expenses professional fees incurred | 2012-12-31 | $160,959 |
| Was this plan covered by a fidelity bond | 2012-12-31 | Yes |
| Value of fidelity bond cover | 2012-12-31 | $50,000,000 |
| If this is an individual account plan, was there a blackout period | 2012-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-12-31 | No |
| Contributions received from participants | 2012-12-31 | $24,241,969 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2012-12-31 | $46,776 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2012-12-31 | $47,246 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2012-12-31 | $46,695 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2012-12-31 | $47,210 |
| Other income not declared elsewhere | 2012-12-31 | $30,463 |
| Liabilities. Value of operating payables at end of year | 2012-12-31 | $2,628,876 |
| Liabilities. Value of operating payables at beginning of year | 2012-12-31 | $2,828,310 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Value of net income/loss | 2012-12-31 | $23,459,171 |
| Value of net assets at end of year (total assets less liabilities) | 2012-12-31 | $197,485,892 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-12-31 | $174,026,721 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2012-12-31 | $52,189,388 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2012-12-31 | $47,420,478 |
| Value of interest in master investment trust accounts at end of year | 2012-12-31 | $152,276,428 |
| Value of interest in master investment trust accounts at beginning of year | 2012-12-31 | $133,465,298 |
| Value of interest in common/collective trusts at end of year | 2012-12-31 | $3,602,901 |
| Value of interest in common/collective trusts at beginning of year | 2012-12-31 | $3,282,950 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2012-12-31 | $280,465 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2012-12-31 | $334,521 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2012-12-31 | $334,521 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-12-31 | $88,030,793 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2012-12-31 | $5,479,037 |
| Net investment gain or loss from common/collective trusts | 2012-12-31 | $520,628 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2012-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-12-31 | No |
| Contributions received in cash from employer | 2012-12-31 | $91,199,519 |
| Employer contributions (assets) at end of year | 2012-12-31 | $865,505 |
| Employer contributions (assets) at beginning of year | 2012-12-31 | $751,748 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-12-31 | $25,449,928 |
| Contract administrator fees | 2012-12-31 | $3,943,394 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2012-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2012-12-31 | $9,100,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2012-12-31 | $8,400,000 |
| Did the plan have assets held for investment | 2012-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2012-12-31 | Disclaimer |
| Accountancy firm name | 2012-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2012-12-31 | 133891517 |
| 2011 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2011 401k financial data |
|---|
| Unrealized appreciation/depreciation of real estate assets | 2011-12-31 | $268 |
| Total unrealized appreciation/depreciation of assets | 2011-12-31 | $268 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $11,275,520 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $10,141,074 |
| Total income from all sources (including contributions) | 2011-12-31 | $124,715,633 |
| Total loss/gain on sale of assets | 2011-12-31 | $0 |
| Total of all expenses incurred | 2011-12-31 | $122,589,539 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-12-31 | $118,718,433 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-12-31 | $123,204,253 |
| Value of total assets at end of year | 2011-12-31 | $185,302,241 |
| Value of total assets at beginning of year | 2011-12-31 | $182,093,408 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-12-31 | $3,871,106 |
| Total interest from all sources | 2011-12-31 | $-12 |
| Total dividends received (eg from common stock, registered investment company shares) | 2011-12-31 | $923,586 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2011-12-31 | $923,586 |
| Administrative expenses professional fees incurred | 2011-12-31 | $65,326 |
| Was this plan covered by a fidelity bond | 2011-12-31 | Yes |
| Value of fidelity bond cover | 2011-12-31 | $50,000,000 |
| If this is an individual account plan, was there a blackout period | 2011-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-12-31 | No |
| Contributions received from participants | 2011-12-31 | $24,483,936 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2011-12-31 | $441,413 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2011-12-31 | $47,246 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2011-12-31 | $59,753 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2011-12-31 | $47,210 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2011-12-31 | $51,759 |
| Administrative expenses (other) incurred | 2011-12-31 | $811,052 |
| Liabilities. Value of operating payables at end of year | 2011-12-31 | $2,828,310 |
| Liabilities. Value of operating payables at beginning of year | 2011-12-31 | $3,689,315 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Value of net income/loss | 2011-12-31 | $2,126,094 |
| Value of net assets at end of year (total assets less liabilities) | 2011-12-31 | $174,026,721 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-12-31 | $171,952,334 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2011-12-31 | $47,420,478 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2011-12-31 | $48,955,122 |
| Value of interest in master investment trust accounts at end of year | 2011-12-31 | $133,465,298 |
| Value of interest in master investment trust accounts at beginning of year | 2011-12-31 | $129,119,376 |
| Value of interest in common/collective trusts at end of year | 2011-12-31 | $3,282,950 |
| Value of interest in common/collective trusts at beginning of year | 2011-12-31 | $3,408,517 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2011-12-31 | $334,521 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2011-12-31 | $550,640 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2011-12-31 | $550,640 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2011-12-31 | $-12 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-12-31 | $84,049,201 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2011-12-31 | $-665,729 |
| Net investment gain or loss from common/collective trusts | 2011-12-31 | $75,359 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-12-31 | No |
| Contributions received in cash from employer | 2011-12-31 | $98,720,317 |
| Employer contributions (assets) at end of year | 2011-12-31 | $751,748 |
| Employer contributions (assets) at beginning of year | 2011-12-31 | $0 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-12-31 | $34,227,819 |
| Contract administrator fees | 2011-12-31 | $2,994,728 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2011-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2011-12-31 | $8,400,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2011-12-31 | $6,400,000 |
| Did the plan have assets held for investment | 2011-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2011-12-31 | Disclaimer |
| Accountancy firm name | 2011-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2011-12-31 | 133891517 |
| 2010 : NISOURCE LIFE AND MEDICAL BENEFITS PROGRAM 2010 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2010-12-31 | $0 |
| Total transfer of assets from this plan | 2010-12-31 | $109,560,219 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2010-12-31 | $10,141,074 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2010-12-31 | $13,861,357 |
| Total income from all sources (including contributions) | 2010-12-31 | $152,864,410 |
| Total loss/gain on sale of assets | 2010-12-31 | $0 |
| Total of all expenses incurred | 2010-12-31 | $126,776,925 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2010-12-31 | $122,307,969 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2010-12-31 | $132,986,290 |
| Value of total assets at end of year | 2010-12-31 | $182,093,408 |
| Value of total assets at beginning of year | 2010-12-31 | $269,286,425 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2010-12-31 | $4,468,956 |
| Total interest from all sources | 2010-12-31 | $21 |
| Total dividends received (eg from common stock, registered investment company shares) | 2010-12-31 | $2,505,675 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2010-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2010-12-31 | $2,505,675 |
| Administrative expenses professional fees incurred | 2010-12-31 | $256,502 |
| Was this plan covered by a fidelity bond | 2010-12-31 | Yes |
| Value of fidelity bond cover | 2010-12-31 | $50,000,000 |
| If this is an individual account plan, was there a blackout period | 2010-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2010-12-31 | No |
| Contributions received from participants | 2010-12-31 | $26,723,615 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2010-12-31 | $2,891,159 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2010-12-31 | $59,753 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2010-12-31 | $223,680 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2010-12-31 | $51,759 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2010-12-31 | $324,798 |
| Other income not declared elsewhere | 2010-12-31 | $-854 |
| Administrative expenses (other) incurred | 2010-12-31 | $235,857 |
| Liabilities. Value of operating payables at end of year | 2010-12-31 | $3,689,315 |
| Liabilities. Value of operating payables at beginning of year | 2010-12-31 | $4,643,559 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Value of net income/loss | 2010-12-31 | $26,087,485 |
| Value of net assets at end of year (total assets less liabilities) | 2010-12-31 | $171,952,334 |
| Value of net assets at beginning of year (total assets less liabilities) | 2010-12-31 | $255,425,068 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2010-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2010-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2010-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2010-12-31 | $48,955,122 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2010-12-31 | $244,950,338 |
| Value of interest in master investment trust accounts at end of year | 2010-12-31 | $129,119,376 |
| Value of interest in master investment trust accounts at beginning of year | 2010-12-31 | $0 |
| Value of interest in common/collective trusts at end of year | 2010-12-31 | $3,408,517 |
| Value of interest in common/collective trusts at beginning of year | 2010-12-31 | $17,603,162 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2010-12-31 | $550,640 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2010-12-31 | $2,033,747 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2010-12-31 | $2,033,747 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2010-12-31 | $21 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2010-12-31 | $77,162,763 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2010-12-31 | $522,941 |
| Net investment gain or loss from common/collective trusts | 2010-12-31 | $349,718 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2010-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2010-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2010-12-31 | No |
| Contributions received in cash from employer | 2010-12-31 | $106,262,675 |
| Employer contributions (assets) at end of year | 2010-12-31 | $0 |
| Employer contributions (assets) at beginning of year | 2010-12-31 | $4,475,498 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2010-12-31 | $42,254,047 |
| Contract administrator fees | 2010-12-31 | $3,976,597 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2010-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2010-12-31 | $6,400,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2010-12-31 | $8,893,000 |
| Did the plan have assets held for investment | 2010-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2010-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2010-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2010-12-31 | Disclaimer |
| Accountancy firm name | 2010-12-31 | DELOITTE & TOUCHE LLP |
| Accountancy firm EIN | 2010-12-31 | 133891517 |
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136* |
| Policy instance | 5 |
| Insurance contract or identification number | 34136* | | Number of Individuals Covered | 7510 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | 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 | 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 $2,380,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136* |
| Policy instance | 4 |
| Insurance contract or identification number | 34136* | | Number of Individuals Covered | 13145 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $48,674 | | 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 | 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 $5,038,926 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,674 | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 0868313HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 0868313HNO | | Number of Individuals Covered | 11 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | 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 $278,459 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 2 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,470 | | 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 $340,234 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,560 | | Insurance broker organization code? | 3 |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | *SEE BELOW |
| Policy instance | 1 |
| Insurance contract or identification number | *SEE BELOW | | Number of Individuals Covered | 19 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,111 | | 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 $310,674 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,849 | | Insurance broker organization code? | 3 |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34137 |
| Policy instance | 6 |
| Insurance contract or identification number | 34137 | | Number of Individuals Covered | 5068 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $21,114 | | 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 | 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 $211,143 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,114 | | Insurance broker organization code? | 3 |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 2 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,534 | | 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 $351,208 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,534 | | Insurance broker organization code? | 3 |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | *SEE BELOW |
| Policy instance | 1 |
| Insurance contract or identification number | *SEE BELOW | | Number of Individuals Covered | 24 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,447 | | 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 $306,760 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,447 | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 0868313HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 0868313HNO | | Number of Individuals Covered | 138 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | 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 | | 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 $2,020,138 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136* |
| Policy instance | 4 |
| Insurance contract or identification number | 34136* | | Number of Individuals Covered | 13079 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $47,770 | | 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 | 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 $4,679,026 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $47,770 | | Insurance broker organization code? | 3 |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136* |
| Policy instance | 5 |
| Insurance contract or identification number | 34136* | | Number of Individuals Covered | 7830 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | 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 | 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 $2,650,389 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34137 |
| Policy instance | 6 |
| Insurance contract or identification number | 34137 | | Number of Individuals Covered | 5122 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $21,282 | | 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 | 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 $212,817 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,282 | | Insurance broker organization code? | 3 |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | *SEE BELOW |
| Policy instance | 1 |
| Insurance contract or identification number | *SEE BELOW | | Number of Individuals Covered | 33 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $29,412 | | 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 $2,477,984 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,412 | | Insurance broker organization code? | 3 |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 2 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $27,642 | | 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 $2,358,212 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,642 | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 0868313HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 0868313HNO | | Number of Individuals Covered | 224 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | 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 | | 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 $2,828,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G* |
| Policy instance | 4 |
| Insurance contract or identification number | 34136-G* | | Number of Individuals Covered | 13319 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $51,081 | | 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 | 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 $4,980,981 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $51,081 | | Insurance broker organization code? | 3 |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G* |
| Policy instance | 5 |
| Insurance contract or identification number | 34136-G* | | Number of Individuals Covered | 8772 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | 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 | 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 $2,774,224 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34137-G |
| Policy instance | 6 |
| Insurance contract or identification number | 34137-G | | Number of Individuals Covered | 5295 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $23,474 | | 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 | 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 $234,737 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,474 | | Insurance broker organization code? | 3 |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 2 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $23,982 | | 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 $2,631,848 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,982 | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 0868313HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 0868313HNO | | Number of Individuals Covered | 399 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 | | 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 $3,867,396 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G* |
| Policy instance | 5 |
| Insurance contract or identification number | 34136-G* | | Number of Individuals Covered | 8775 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 | 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 $2,785,801 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | *SEE BELOW |
| Policy instance | 1 |
| Insurance contract or identification number | *SEE BELOW | | Number of Individuals Covered | 326 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $27,447 | | 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 $3,011,744 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,447 | | Insurance broker organization code? | 3 |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34137-G |
| Policy instance | 6 |
| Insurance contract or identification number | 34137-G | | Number of Individuals Covered | 5475 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $22,754 | | 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 | 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 $227,537 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,754 | | Insurance broker organization code? | 3 |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G* |
| Policy instance | 4 |
| Insurance contract or identification number | 34136-G* | | Number of Individuals Covered | 13430 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $50,244 | | 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 | 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 $4,103,584 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $50,244 | | Insurance broker organization code? | 3 |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | *SEE BELOW |
| Policy instance | 1 |
| Insurance contract or identification number | *SEE BELOW | | Number of Individuals Covered | 319 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $28,246 | | 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 $2,808,625 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,246 | | Insurance broker organization code? | 3 |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 2 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $24,388 | | 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 $2,448,271 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,388 | | Insurance broker organization code? | 3 |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G* |
| Policy instance | 4 |
| Insurance contract or identification number | 34136-G* | | Number of Individuals Covered | 13418 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $49,828 | | 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 | 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 $4,035,954 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,828 | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 0868313HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 0868313HNO | | Number of Individuals Covered | 514 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | 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 | | 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 $3,900,035 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G* |
| Policy instance | 5 |
| Insurance contract or identification number | 34136-G* | | Number of Individuals Covered | 10686 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | 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 | 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 $2,760,399 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34137-G |
| Policy instance | 6 |
| Insurance contract or identification number | 34137-G | | Number of Individuals Covered | 5506 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $22,706 | | 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 | 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 $227,058 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,706 | | Insurance broker organization code? | 3 |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34137-G |
| Policy instance | 6 |
| Insurance contract or identification number | 34137-G | | Number of Individuals Covered | 5621 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $22,606 | | 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 | 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 $226,063 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,606 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRIFF SEIBELS AND WILLIAMS INC |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 07522000* |
| Policy instance | 1 |
| Insurance contract or identification number | 07522000* | | Number of Individuals Covered | 349 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $29,316 | | 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 $2,946,075 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,016 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 2 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $20,733 | | 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 $2,375,115 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,733 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 0868313HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 0868313HNO | | Number of Individuals Covered | 483 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | 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 $3,614,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G |
| Policy instance | 5 |
| Insurance contract or identification number | 34136-G | | Number of Individuals Covered | 10521 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | 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 | 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 $2,706,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G |
| Policy instance | 4 |
| Insurance contract or identification number | 34136-G | | Number of Individuals Covered | 13134 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $48,832 | | 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 | 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 $3,994,757 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,832 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRIFF SEIBELS & WILLIAMS INC |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 5 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 177 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $22,456 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $2,268,179 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,456 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | *07522000 |
| Policy instance | 4 |
| Insurance contract or identification number | *07522000 | | Number of Individuals Covered | 393 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $27,973 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $2,803,075 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,973 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 08840472 |
| Policy instance | 3 |
| Insurance contract or identification number | 08840472 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $173,793 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF OHIO (National Association of Insurance Commissioners NAIC id number: 95204 ) |
| Policy contract number | 2154 |
| Policy instance | 2 |
| Insurance contract or identification number | 2154 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,983 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $198,274 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,983 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES LLC |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 514889 |
| Policy instance | 1 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $3,648 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $155,358 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,648 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 715179 |
| Policy instance | 6 |
| Insurance contract or identification number | 715179 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $3,994 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $361,755 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3994 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 93191 |
| Policy instance | 7 |
| Insurance contract or identification number | 93191 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 $1,666 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G |
| Policy instance | 9 |
| Insurance contract or identification number | 34136-G | | Number of Individuals Covered | 11061 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $2,790,012 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34137-G |
| Policy instance | 10 |
| Insurance contract or identification number | 34137-G | | Number of Individuals Covered | 5714 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $27,840 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $278,298 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,840 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRIFF SEIBELS AND WILLIAMS OF TX |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 514889 |
| Policy instance | 11 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $23,419 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHAMERICA OF PENNSYLVANIA, INC. HMO (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 5302070000 |
| Policy instance | 8 |
| Insurance contract or identification number | 5302070000 | | Number of Individuals Covered | 665 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $48,171 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $4,817,103 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,171 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE AGENCY |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G |
| Policy instance | 12 |
| Insurance contract or identification number | 34136-G | | Number of Individuals Covered | 15372 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $49,335 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $3,924,691 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,335 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRIFF SEIBELS AND WILLIAMS OF TX |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G |
| Policy instance | 14 |
| Insurance contract or identification number | 34136-G | | Number of Individuals Covered | 14864 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $50,963 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $4,355,554 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $50,963 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRIFF SELBELS AND WILLIAMS OF TX |
|
| SH-COVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 96555 ) |
| Policy contract number | 3454800000 |
| Policy instance | 13 |
| Insurance contract or identification number | 3454800000 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $13 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,255 | | 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 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES LLC |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 08840472 |
| Policy instance | 3 |
| Insurance contract or identification number | 08840472 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $194,844 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 514889 |
| Policy instance | 1 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $6,912 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $239,414 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,912 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 514889 |
| Policy instance | 12 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $37,809 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF OHIO (National Association of Insurance Commissioners NAIC id number: 95204 ) |
| Policy contract number | 2154 |
| Policy instance | 2 |
| Insurance contract or identification number | 2154 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,495 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $149,547 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,495 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES LLC |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | *07522000 |
| Policy instance | 4 |
| Insurance contract or identification number | *07522000 | | Number of Individuals Covered | 404 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $26,757 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $2,672,174 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,757 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 5 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $20,701 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $2,077,658 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,701 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 715179 |
| Policy instance | 6 |
| Insurance contract or identification number | 715179 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $5,952 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $562,541 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 5952 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 93191 |
| Policy instance | 7 |
| Insurance contract or identification number | 93191 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 $3,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CARELINK OF WV (National Association of Insurance Commissioners NAIC id number: 95408 ) |
| Policy contract number | 8004560000 |
| Policy instance | 8 |
| Insurance contract or identification number | 8004560000 | | Number of Individuals Covered | 69 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $8,149 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $814,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,149 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES LLC |
|
| HEALTHAMERICA OF PENNSYLVANIA, INC. HMO (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 5302070000 |
| Policy instance | 9 |
| Insurance contract or identification number | 5302070000 | | Number of Individuals Covered | 890 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $53,141 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $5,314,064 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,141 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE AGENCY |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G |
| Policy instance | 10 |
| Insurance contract or identification number | 34136-G | | Number of Individuals Covered | 10768 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $2,952,759 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34137-G |
| Policy instance | 11 |
| Insurance contract or identification number | 34137-G | | Number of Individuals Covered | 7221 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $33,309 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $333,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,309 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRIFF SEIBELS AND WILLIAMS OF TX |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | *85862000 |
| Policy instance | 8 |
| Insurance contract or identification number | 052706-C | | Number of Individuals Covered | 34 | | Insurance policy end date | 2012-12-31 | | Total amount of fees paid to insurance company | USD $74 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance policy start date | 2013-01-01 | | Total amount of commissions paid to insurance broker | USD $2,616 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $258,635 | | Amount paid for insurance broker fees | 23 | | Additional information about fees paid to insurance broker | COMPENSATION 3 | | Commission paid to Insurance Broker | USD $2,616 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 60117000 |
| Policy instance | 7 |
| Insurance contract or identification number | 60117000 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $15,507 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,570,814 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,507 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 6 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $20,210 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $2,034,887 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,210 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | *07522000 |
| Policy instance | 5 |
| Insurance contract or identification number | *07522000 | | Number of Individuals Covered | 44 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $8,183 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $819,835 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,183 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | 00092240 |
| Policy instance | 4 |
| Insurance contract or identification number | 00092240 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $478,562 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 08840472* |
| Policy instance | 3 |
| Insurance contract or identification number | 08840472* | | Number of Individuals Covered | 34 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $194,472 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF OHIO (National Association of Insurance Commissioners NAIC id number: 95204 ) |
| Policy contract number | 2154 |
| Policy instance | 2 |
| Insurance contract or identification number | 2154 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $1,574 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $168,337 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,574 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES LLC |
|
| CARELINK OF WV (National Association of Insurance Commissioners NAIC id number: 95408 ) |
| Policy contract number | 8004560000 |
| Policy instance | 11 |
| Insurance contract or identification number | 8004560000 | | Number of Individuals Covered | 483 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $35,012 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $3,501,223 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,012 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES LLC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 715179 |
| Policy instance | 9 |
| Insurance contract or identification number | 715179 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $747 | | Total amount of fees paid to insurance company | USD $7,147 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $761,193 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $747 | | Amount paid for insurance broker fees | 7147 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 93191-7 |
| Policy instance | 10 |
| Insurance contract or identification number | 93191-7 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 $2,657 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 514889 |
| Policy instance | 17 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $40,351 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHAMERICA OF PENNSYLVANIA, INC. HMO (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 5302070000 |
| Policy instance | 12 |
| Insurance contract or identification number | 5302070000 | | Number of Individuals Covered | 917 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $54,768 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $5,476,806 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,768 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE AGENCY |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G |
| Policy instance | 13 |
| Insurance contract or identification number | 34136-G | | Number of Individuals Covered | 10527 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $2,709,099 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34137-G |
| Policy instance | 14 |
| Insurance contract or identification number | 34137-G | | Number of Individuals Covered | 7418 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $33,675 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 $337,066 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,675 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRIFF SEIBELS AND WILLIAMS OF TX |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 003327107 |
| Policy instance | 16 |
| Insurance contract or identification number | 003327107 | | Number of Individuals Covered | 27999 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $240,530 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $357,012 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $160,633 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 60117901 |
| Policy instance | 15 |
| Insurance contract or identification number | 60117901 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $786 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $79,796 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $786 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| SH-COVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 96555 ) |
| Policy contract number | 345400000 |
| Policy instance | 18 |
| Insurance contract or identification number | 345400000 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $20,254 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $2,025,427 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,254 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES LLC |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34136-G |
| Policy instance | 19 |
| Insurance contract or identification number | 34136-G | | Number of Individuals Covered | 14512 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $48,518 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $4,160,109 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,518 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRIFF SELBELS AND WILLIAMS OF TX |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 514889 |
| Policy instance | 1 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $7,656 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $290,339 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,656 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 098670 |
| Policy instance | 13 |
| Insurance contract or identification number | 098670 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $52 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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? | No | | Commission paid to Insurance Broker | USD $52 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 85862000-901 |
| Policy instance | 12 |
| Insurance contract or identification number | 85862000-901 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $363,379 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 514889 |
| Policy instance | 14 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $72,679 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SH-COVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 96555 ) |
| Policy contract number | 3454800000 |
| Policy instance | 15 |
| Insurance contract or identification number | 3454800000 | | Number of Individuals Covered | 327 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $21,253 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $2,125,260 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,253 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES LLC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0715179 |
| Policy instance | 16 |
| Insurance contract or identification number | 0715179 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $8,325 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $834,721 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,325 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 93191-7 |
| Policy instance | 17 |
| Insurance contract or identification number | 93191-7 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 $2,682 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHAMERICA OF PENNSYLVANIA, INC. HMO (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 5302070000 |
| Policy instance | 19 |
| Insurance contract or identification number | 5302070000 | | Number of Individuals Covered | 983 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $48,890 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $4,885,661 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,890 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE AGENCY |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 00000 |
| Policy instance | 20 |
| Insurance contract or identification number | 00000 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $295,435 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $295,435 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 514889 |
| Policy instance | 1 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $13,128 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $515,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,128 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 60117000-901 |
| Policy instance | 11 |
| Insurance contract or identification number | 60117000-901 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,518,983 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 10 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 148 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $19,596 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,971,117 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,596 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE |
|
| KAISER FOUNDATION HEALTH PLAN OF OHIO (National Association of Insurance Commissioners NAIC id number: 95204 ) |
| Policy contract number | 2154 |
| Policy instance | 2 |
| Insurance contract or identification number | 2154 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,108 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $212,527 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,108 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES LLC |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 08840472* |
| Policy instance | 4 |
| Insurance contract or identification number | 08840472* | | Number of Individuals Covered | 36 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $200,640 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 064263 |
| Policy instance | 3 |
| Insurance contract or identification number | 064263 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $17,734 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $640,537 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,734 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | 00092240 |
| Policy instance | 5 |
| Insurance contract or identification number | 00092240 | | Number of Individuals Covered | 89 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $581,172 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 93191-2-3 |
| Policy instance | 6 |
| Insurance contract or identification number | 93191-2-3 | | Number of Individuals Covered | 29982 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $5,917,269 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 93191-4 |
| Policy instance | 7 |
| Insurance contract or identification number | 93191-4 | | Number of Individuals Covered | 10282 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $82,811 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | 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 $828,104 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $82,811 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRIFF SEIBELS & WILLIAMS TX LIFE |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 93191-5 |
| Policy instance | 8 |
| Insurance contract or identification number | 93191-5 | | Number of Individuals Covered | 4314 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $30,768 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | 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 $307,682 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,768 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRIFF SEIBELS & WILLIAMS TX LIFE |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 7522000-901 |
| Policy instance | 9 |
| Insurance contract or identification number | 7522000-901 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,199 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $643,297 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,199 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE LLC |
|
| CARELINK OF WV (National Association of Insurance Commissioners NAIC id number: 95408 ) |
| Policy contract number | 8004560000 |
| Policy instance | 18 |
| Insurance contract or identification number | 8004560000 | | Number of Individuals Covered | 627 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $39,451 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $3,945,124 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,451 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT ASSOCIATES LLC |
|
| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | 00092240 |
| Policy instance | 1 |
| Insurance contract or identification number | 00092240 | | Number of Individuals Covered | 90 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $53,825 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $778,738 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | SEE BELOW* |
| Policy instance | 19 |
| Insurance contract or identification number | SEE BELOW* | | Number of Individuals Covered | 37 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $489,611 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 514889 |
| Policy instance | 2 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $85,742 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0715179 |
| Policy instance | 20 |
| Insurance contract or identification number | 0715179 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $8,826 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $883,349 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | SEE BELOW* |
| Policy instance | 18 |
| Insurance contract or identification number | SEE BELOW* | | Number of Individuals Covered | 103 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,208,644 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | SEE BELOW* |
| Policy instance | 17 |
| Insurance contract or identification number | SEE BELOW* | | Number of Individuals Covered | 43 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $25,877 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $908,652 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 0000093191* |
| Policy instance | 12 |
| Insurance contract or identification number | 0000093191* | | Number of Individuals Covered | 28496 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $5,904,925 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 95828 ) |
| Policy contract number | 681026 |
| Policy instance | 11 |
| Insurance contract or identification number | 681026 | | Number of Individuals Covered | 557 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $24,572 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $11,124 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | *584222 |
| Policy instance | 10 |
| Insurance contract or identification number | *584222 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $214,130 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF OHIO (National Association of Insurance Commissioners NAIC id number: 95204 ) |
| Policy contract number | 2154 |
| Policy instance | 8 |
| Insurance contract or identification number | 2154 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $1,865 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $187,548 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHAMERICA OF PENNSYLVANIA, INC. HMO (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 5302070000 |
| Policy instance | 7 |
| Insurance contract or identification number | 5302070000 | | Number of Individuals Covered | 403 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $54,883 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $5,488,322 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 6 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $18,522 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,872,024 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 098670 |
| Policy instance | 5 |
| Insurance contract or identification number | 098670 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $1,242 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $49,068 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 064263 |
| Policy instance | 4 |
| Insurance contract or identification number | 064263 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $26,979 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $1,158,673 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CARELINK OF WV (National Association of Insurance Commissioners NAIC id number: 95408 ) |
| Policy contract number | 8004560000 |
| Policy instance | 3 |
| Insurance contract or identification number | 8004560000 | | Number of Individuals Covered | 704 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $40,485 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $4,056,523 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | SEE BELOW* |
| Policy instance | 13 |
| Insurance contract or identification number | SEE BELOW* | | Number of Individuals Covered | 9828 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $27,980 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | 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 $279,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 514889 |
| Policy instance | 9 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $15,216 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $557,734 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SH-COVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 96555 ) |
| Policy contract number | 3454800000 |
| Policy instance | 16 |
| Insurance contract or identification number | 3454800000 | | Number of Individuals Covered | 704 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $25,235 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $2,527,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | *SEE BELOW |
| Policy instance | 15 |
| Insurance contract or identification number | *SEE BELOW | | Number of Individuals Covered | 26 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 $2,691 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | SEE BELOW* |
| Policy instance | 14 |
| Insurance contract or identification number | SEE BELOW* | | Number of Individuals Covered | 10484 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $33,424 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | 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 $334,238 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | SEE BELOW* |
| Policy instance | 21 |
| Insurance contract or identification number | SEE BELOW* | | Number of Individuals Covered | 40 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $537,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | SEE BELOW* |
| Policy instance | 16 |
| Insurance contract or identification number | SEE BELOW* | | Number of Individuals Covered | 10637 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $33,102 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $331,024 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | SEE BELOW* |
| Policy instance | 18 |
| Insurance contract or identification number | SEE BELOW* | | Number of Individuals Covered | 43 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $24,372 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $833,893 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH NEW ENGLAND, INC. (National Association of Insurance Commissioners NAIC id number: 95673 ) |
| Policy contract number | 111161 |
| Policy instance | 8 |
| Insurance contract or identification number | 111161 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $18,165 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,829,422 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | SEE BELOW* |
| Policy instance | 19 |
| Insurance contract or identification number | SEE BELOW* | | Number of Individuals Covered | 87 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $984,858 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 514889 |
| Policy instance | 11 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $21,672 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $696,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHAMERICA OF PENNSYLVANIA, INC. HMO (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 5302070000 |
| Policy instance | 24 |
| Insurance contract or identification number | 5302070000 | | Number of Individuals Covered | 1117 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $59,556 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $5,955,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 600117901 |
| Policy instance | 20 |
| Insurance contract or identification number | 600117901 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $33,832 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0715179 |
| Policy instance | 23 |
| Insurance contract or identification number | 0715179 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $8,990 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $900,747 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
| Policy contract number | 85862901 |
| Policy instance | 22 |
| Insurance contract or identification number | 85862901 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $51,004 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | SEE BELOW* |
| Policy instance | 15 |
| Insurance contract or identification number | SEE BELOW* | | Number of Individuals Covered | 9560 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $26,841 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $261,892 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 0000093191* |
| Policy instance | 14 |
| Insurance contract or identification number | 0000093191* | | Number of Individuals Covered | 27692 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $652 | | Total amount of fees paid to insurance company | USD $3,207 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $5,460,826 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 064263 |
| Policy instance | 6 |
| Insurance contract or identification number | 064263 | | Number of Individuals Covered | 387 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $37,628 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $2,298,569 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CARELINK OF WV (National Association of Insurance Commissioners NAIC id number: 95408 ) |
| Policy contract number | 8004560000 |
| Policy instance | 5 |
| Insurance contract or identification number | 8004560000 | | Number of Individuals Covered | 864 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $17,416 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $4,132,364 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 514889 |
| Policy instance | 4 |
| Insurance contract or identification number | 514889 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $116,121 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | 00092240 |
| Policy instance | 3 |
| Insurance contract or identification number | 00092240 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $963,291 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95490 ) |
| Policy contract number | US002620 |
| Policy instance | 2 |
| Insurance contract or identification number | US002620 | | Number of Individuals Covered | 1016 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $66,158 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $5,718,066 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VALUEOPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 62199 ) |
| Policy contract number | 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 00000 | | Number of Individuals Covered | 15016 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | EMPLOYEE ASSISTANCE PROGRAM | | 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 $180,327 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHAMERICA OF PENNSYLVANIA, INC. HMO (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 5302070000 |
| Policy instance | 9 |
| Insurance contract or identification number | 5302070000 | | Number of Individuals Covered | 1117 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $59,556 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $5,955,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF OHIO (National Association of Insurance Commissioners NAIC id number: 95204 ) |
| Policy contract number | 2154 |
| Policy instance | 10 |
| Insurance contract or identification number | 2154 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $1,751 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $175,907 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SH-COVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 96555 ) |
| Policy contract number | 3454800000 |
| Policy instance | 17 |
| Insurance contract or identification number | 3454800000 | | Number of Individuals Covered | 559 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $10,924 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $2,781,112 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 584222(5-9) |
| Policy instance | 12 |
| Insurance contract or identification number | 584222(5-9) | | Number of Individuals Covered | 41 | | Insurance policy start date | 2009-07-01 | | Insurance policy end date | 2010-06-30 | | 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? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $198,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 95828 ) |
| Policy contract number | 681026 |
| Policy instance | 13 |
| Insurance contract or identification number | 681026 | | Number of Individuals Covered | 570 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $27,364 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $13,439 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 098670 |
| Policy instance | 7 |
| Insurance contract or identification number | 098670 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $2,552 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | 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 $2,298,506 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
