401k Plan data: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN plan

MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN
Plan identification number	501

MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Prepaid legal Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

MOELLER MFG. COMPANY LLC has sponsored the creation of one or more 401k plans.

Company Name: MOELLER MFG. COMPANY LLC

Employer identification number (EIN): 381723023

NAIC Classification: 333610

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 FRANK LITFIN 2023-07-06
501 2021-01-01 FRANK LITFIN 2022-06-21
501 2020-01-01 FRANK G. LITFIN III 2021-05-26
501 2020-01-01 FRANK LITFIN 2022-06-23
501 2019-01-01 FRANK G. LITFIN III 2020-06-29
501 2018-01-01
501 2017-01-01
501 2016-01-01 FRANK G LITFIN III
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 JOSEPH R. BAKER
501 2011-01-01 JOSEPH R. BAKER
501 2010-01-01 JOSEPH R. BAKER
501 2009-01-01 JOSEPH BAKER
501 2009-01-01 JOSEPH BAKER
501 2009-01-01 JOSEPH BAKER
501 2009-01-01 JOSEPH BAKER

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	FRANK LITFIN	2023-07-06
501	2021-01-01	FRANK LITFIN	2022-06-21
501	2020-01-01	FRANK G. LITFIN III	2021-05-26
501	2020-01-01	FRANK LITFIN	2022-06-23
501	2019-01-01	FRANK G. LITFIN III	2020-06-29
501	2018-01-01
501	2017-01-01
501	2016-01-01	FRANK G LITFIN III
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	JOSEPH R. BAKER
501	2011-01-01	JOSEPH R. BAKER
501	2010-01-01	JOSEPH R. BAKER
501	2009-01-01	JOSEPH BAKER
501	2009-01-01	JOSEPH BAKER
501	2009-01-01	JOSEPH BAKER
501	2009-01-01	JOSEPH BAKER

Plan Statistics for MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN

401k plan membership statisitcs for MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN

Measure Date Value
2022: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 431
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 389
Number of retired or separated participants receiving benefits 2022-01-01 2
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 391
Number of employers contributing to the scheme 2022-01-01 0
2021: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 446
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 431
Number of retired or separated participants receiving benefits 2021-01-01 8
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 439
Number of employers contributing to the scheme 2021-01-01 0
2020: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 714
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 446
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 446
Number of employers contributing to the scheme 2020-01-01 0
2019: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 598
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 714
Number of retired or separated participants receiving benefits 2019-01-01 8
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 722
Number of employers contributing to the scheme 2019-01-01 0
2018: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 518
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 598
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 598
Number of employers contributing to the scheme 2018-01-01 0
2017: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 754
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 518
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 518
2016: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 651
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 754
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 754
2015: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 689
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 643
Number of retired or separated participants receiving benefits 2015-01-01 8
Total of all active and inactive participants 2015-01-01 651
2014: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 762
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 682
Number of retired or separated participants receiving benefits 2014-01-01 7
Total of all active and inactive participants 2014-01-01 689
2013: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 772
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 762
Number of retired or separated participants receiving benefits 2013-01-01 7
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 769
2012: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 645
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 772
Number of retired or separated participants receiving benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 772
Number of employers contributing to the scheme 2012-01-01 2
2011: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 584
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 636
Number of retired or separated participants receiving benefits 2011-01-01 9
Total of all active and inactive participants 2011-01-01 645
Number of employers contributing to the scheme 2011-01-01 2
2010: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 530
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 577
Number of retired or separated participants receiving benefits 2010-01-01 7
Total of all active and inactive participants 2010-01-01 584
Number of employers contributing to the scheme 2010-01-01 2
2009: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 433
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 518
Number of retired or separated participants receiving benefits 2009-01-01 12
Total of all active and inactive participants 2009-01-01 530
Number of employers contributing to the scheme 2009-01-01 2

Measure	Date	Value
2022: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	431
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	389
Number of retired or separated participants receiving benefits	2022-01-01	2
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	391
Number of employers contributing to the scheme	2022-01-01	0
2021: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	446
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	431
Number of retired or separated participants receiving benefits	2021-01-01	8
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	439
Number of employers contributing to the scheme	2021-01-01	0
2020: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	714
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	446
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	446
Number of employers contributing to the scheme	2020-01-01	0
2019: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	598
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	714
Number of retired or separated participants receiving benefits	2019-01-01	8
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	722
Number of employers contributing to the scheme	2019-01-01	0
2018: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	518
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	598
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	598
Number of employers contributing to the scheme	2018-01-01	0
2017: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	754
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	518
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	518
2016: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	651
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	754
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	754
2015: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	689
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	643
Number of retired or separated participants receiving benefits	2015-01-01	8
Total of all active and inactive participants	2015-01-01	651
2014: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	762
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	682
Number of retired or separated participants receiving benefits	2014-01-01	7
Total of all active and inactive participants	2014-01-01	689
2013: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	772
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	762
Number of retired or separated participants receiving benefits	2013-01-01	7
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	769
2012: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	645
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	772
Number of retired or separated participants receiving benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	772
Number of employers contributing to the scheme	2012-01-01	2
2011: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	584
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	636
Number of retired or separated participants receiving benefits	2011-01-01	9
Total of all active and inactive participants	2011-01-01	645
Number of employers contributing to the scheme	2011-01-01	2
2010: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	530
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	577
Number of retired or separated participants receiving benefits	2010-01-01	7
Total of all active and inactive participants	2010-01-01	584
Number of employers contributing to the scheme	2010-01-01	2
2009: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	433
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	518
Number of retired or separated participants receiving benefits	2009-01-01	12
Total of all active and inactive participants	2009-01-01	530
Number of employers contributing to the scheme	2009-01-01	2

Form 5500 Responses for MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN

2022: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan is a collectively bargained plan	Yes
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan is a collectively bargained plan	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan is a collectively bargained plan	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Multi-employer plan
2012-01-01	Plan is a collectively bargained plan	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Multi-employer plan
2011-01-01	Plan is a collectively bargained plan	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Multi-employer plan
2010-01-01	Plan is a collectively bargained plan	Yes
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: MOLLER MFG. COMPANY HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Multi-employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	This submission is the final filing	No
2009-01-01	Plan is a collectively bargained plan	Yes
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

204280

Policy instance

Insurance contract or identification number	204280
Number of Individuals Covered	49
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,990
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $1,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,747
Amount paid for insurance broker fees	0
Insurance broker organization code?	4

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

886442G

Policy instance

Insurance contract or identification number	886442G
Number of Individuals Covered	427
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $95,972
Total amount of fees paid to insurance company	USD $18,622
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $662,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $95,972
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10201891001

Policy instance

Insurance contract or identification number	10201891001
Number of Individuals Covered	823
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,916
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $44,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,916
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10201891001

Policy instance

Insurance contract or identification number	10201891001
Number of Individuals Covered	940
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,152
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $47,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,152
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

204280

Policy instance

Insurance contract or identification number	204280
Number of Individuals Covered	52
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,573
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $8,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,445
Amount paid for insurance broker fees	0
Insurance broker organization code?	4

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

886442G

Policy instance

Insurance contract or identification number	886442G
Number of Individuals Covered	431
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $81,097
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $564,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $81,097
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

886442G

Policy instance

Insurance contract or identification number	886442G
Number of Individuals Covered	446
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $93,716
Total amount of fees paid to insurance company	USD $13,990
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $652,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $93,716
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

204280

Policy instance

Insurance contract or identification number	204280
Number of Individuals Covered	58
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,608
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $12,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,176
Amount paid for insurance broker fees	0
Insurance broker organization code?	4

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10201891001

Policy instance

Insurance contract or identification number	10201891001
Number of Individuals Covered	963
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,353
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $91,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,930
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

886442

Policy instance

Insurance contract or identification number	886442
Number of Individuals Covered	714
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $109,864
Total amount of fees paid to insurance company	USD $32,347
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $765,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $109,864
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10201891001

Policy instance

Insurance contract or identification number	10201891001
Number of Individuals Covered	1530
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,317
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $44,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,317
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

366798

Policy instance

Insurance contract or identification number	366798
Number of Individuals Covered	598
Insurance policy start date	2018-02-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $88,238
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $635,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $88,238
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

366798

Policy instance

Insurance contract or identification number	366798
Number of Individuals Covered	561
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $106,668
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $767,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $105,951
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

4393

Policy instance

Insurance contract or identification number	4393
Number of Individuals Covered	399
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,113
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,113
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

97094521001

Policy instance

Insurance contract or identification number	97094521001
Number of Individuals Covered	396
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,342
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,942
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,342
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

97094521001

Policy instance

Insurance contract or identification number	97094521001
Number of Individuals Covered	423
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,663
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,663
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

4393

Policy instance

Insurance contract or identification number	4393
Number of Individuals Covered	422
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,660
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
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 $5,660
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

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

Policy contract number

366798

Policy instance

Insurance contract or identification number	366798
Number of Individuals Covered	518
Insurance policy start date	2016-02-01
Insurance policy end date	2017-01-31
Total amount of commissions paid to insurance broker	USD $149,734
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $850,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $105,370
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES INC

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

4393

Policy instance

Insurance contract or identification number	4393
Number of Individuals Covered	467
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,104
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,104
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFITS SERVICES

MIDWESTERN DENTAL PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 11107 )

Policy contract number

4002

Policy instance

Insurance contract or identification number	4002
Number of Individuals Covered	130
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 $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12701658

Policy instance

Insurance contract or identification number	12701658
Number of Individuals Covered	445
Insurance policy start date	2015-01-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $272
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $272
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFITS SERVICES

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

Policy contract number

00366798

Policy instance

Insurance contract or identification number	00366798
Number of Individuals Covered	799
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $103,697
Total amount of fees paid to insurance company	USD $12,061
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $803,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $86,560
Amount paid for insurance broker fees	12061
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFITS SERVICES

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/SF01

Policy instance

Insurance contract or identification number	00107792/SF01
Number of Individuals Covered	426
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $20,673
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $364,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,673
Additional information about fees paid to insurance broker	INCLUDES ALL BCN SERVICE COMPANY SCHEDULES A
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFITS SERVICES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9709452

Policy instance

Insurance contract or identification number	9709452
Number of Individuals Covered	464
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,978
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,978
Insurance broker name	GALLAGHER BENEFITS SERVICES

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/SF02

Policy instance

Insurance contract or identification number	00107792/SF02
Number of Individuals Covered	251
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 $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $191,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/SF03

Policy instance

Insurance contract or identification number	00107792/SF03
Number of Individuals Covered	253
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 $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $217,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/SF04

Policy instance

Insurance contract or identification number	00107792/SF04
Number of Individuals Covered	100
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 $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

40544-023

Policy instance

Insurance contract or identification number	40544-023
Number of Individuals Covered	13
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $3,277
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,277
Insurance broker name	GALLAGHER BENEFITS SERVICES

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/SF08

Policy instance

Insurance contract or identification number	00107792/SF08
Number of Individuals Covered	1
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 $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/006

Policy instance

Insurance contract or identification number	00107792/006
Number of Individuals Covered	6
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 $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/SF05

Policy instance

Insurance contract or identification number	00107792/SF05
Number of Individuals Covered	70
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 $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,856
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

40544-023

Policy instance

Insurance contract or identification number	40544-023
Number of Individuals Covered	18
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $3,530
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,530
Insurance broker organization code?	3
Insurance broker name	KENT M. GRATHWOHL

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0006

Policy instance

Insurance contract or identification number	00107792/0006
Number of Individuals Covered	3
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $62
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

4393

Policy instance

Insurance contract or identification number	4393
Number of Individuals Covered	557
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,684
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,927
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFITS SERVICES

MIDWESTERN DENTAL PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 11107 )

Policy contract number

4002

Policy instance

Insurance contract or identification number	4002
Number of Individuals Covered	126
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12701658

Policy instance

Insurance contract or identification number	12701658
Number of Individuals Covered	433
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $145
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $145
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFITS SERVICES

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

Policy contract number

00366798

Policy instance

Insurance contract or identification number	00366798
Number of Individuals Covered	884
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $78,487
Total amount of fees paid to insurance company	USD $16,264
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $739,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $78,487
Amount paid for insurance broker fees	16264
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9709452

Policy instance

Insurance contract or identification number	9709452
Number of Individuals Covered	550
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,210
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,210
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0001

Policy instance

Insurance contract or identification number	00107792/0001
Number of Individuals Covered	887
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $14,808
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,633,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,495
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFITS SERVICES

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0002

Policy instance

Insurance contract or identification number	00107792/0002
Number of Individuals Covered	696
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $10,608
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,353,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,802
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFITS SERVICES

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0003

Policy instance

Insurance contract or identification number	00107792/0003
Number of Individuals Covered	296
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $28,408
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,133,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,215
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFITS SERVICES

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0005

Policy instance

Insurance contract or identification number	00107792/0005
Number of Individuals Covered	186
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,127
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $334,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,005
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFITS SERVICES

MIDWESTERN DENTAL PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 11107 )

Policy contract number

4002

Policy instance

Insurance contract or identification number	4002
Number of Individuals Covered	127
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12701658

Policy instance

Insurance contract or identification number	12701658
Number of Individuals Covered	442
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,498
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,498
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

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

Policy contract number

00366798

Policy instance

Insurance contract or identification number	00366798
Number of Individuals Covered	929
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $62,195
Total amount of fees paid to insurance company	USD $14,683
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $601,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,195
Amount paid for insurance broker fees	14683
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0001

Policy instance

Insurance contract or identification number	00107792/0001
Number of Individuals Covered	463
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $17,595
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,168,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,595
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9709452

Policy instance

Insurance contract or identification number	9709452
Number of Individuals Covered	736
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,413
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,413
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0002

Policy instance

Insurance contract or identification number	00107792/0002
Number of Individuals Covered	471
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $14,401
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,019,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,401
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

4393

Policy instance

Insurance contract or identification number	4393
Number of Individuals Covered	743
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,913
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,913
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0003

Policy instance

Insurance contract or identification number	00107792/0003
Number of Individuals Covered	241
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $44,824
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $904,018
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,824
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0006

Policy instance

Insurance contract or identification number	00107792/0006
Number of Individuals Covered	2
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $62
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0005

Policy instance

Insurance contract or identification number	00107792/0005
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 $12,760
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $556,752
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,760
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

40544-023

Policy instance

Insurance contract or identification number	40544-023
Number of Individuals Covered	14
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $2,832
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,832
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

MIDWESTERN DENTAL PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 11107 )

Policy contract number

4002

Policy instance

Insurance contract or identification number	4002
Number of Individuals Covered	130
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/00002

Policy instance

Insurance contract or identification number	00107792/00002
Number of Individuals Covered	507
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $14,064
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,756,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,064
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

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

Policy contract number

00366798

Policy instance

Insurance contract or identification number	00366798
Number of Individuals Covered	747
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $56,252
Total amount of fees paid to insurance company	USD $13,985
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $519,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,252
Amount paid for insurance broker fees	13985
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/00003

Policy instance

Insurance contract or identification number	00107792/00003
Number of Individuals Covered	239
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $45,869
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $974,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,869
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/00001

Policy instance

Insurance contract or identification number	00107792/00001
Number of Individuals Covered	426
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $17,264
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,040,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,264
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0005

Policy instance

Insurance contract or identification number	00107792/0005
Number of Individuals Covered	117
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $24,447
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $562,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,447
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

40544-023

Policy instance

Insurance contract or identification number	40544-023
Number of Individuals Covered	12
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $3,061
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,061
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12701658

Policy instance

Insurance contract or identification number	12701658
Number of Individuals Covered	438
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,377
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,377
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

4393

Policy instance

Insurance contract or identification number	4393
Number of Individuals Covered	819
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,287
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,287
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9709452

Policy instance

Insurance contract or identification number	9709452
Number of Individuals Covered	803
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,706
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,706
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

40544-023

Policy instance

Insurance contract or identification number	40544-023
Number of Individuals Covered	26
Insurance policy start date	2010-02-01
Insurance policy end date	2011-01-31
Total amount of commissions paid to insurance broker	USD $4,420
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $164,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0003

Policy instance

Insurance contract or identification number	00107792/0003
Number of Individuals Covered	215
Insurance policy start date	2010-02-01
Insurance policy end date	2011-01-31
Total amount of commissions paid to insurance broker	USD $16,266
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $837,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/00002

Policy instance

Insurance contract or identification number	00107792/00002
Number of Individuals Covered	347
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $9,564
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,099,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/00001

Policy instance

Insurance contract or identification number	00107792/00001
Number of Individuals Covered	506
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $19,828
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,279,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

4393

Policy instance

Insurance contract or identification number	4393
Number of Individuals Covered	651
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,011
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MIDWESTERN DENTAL PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 11107 )

Policy contract number

4002

Policy instance

Insurance contract or identification number	4002
Number of Individuals Covered	135
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12701658

Policy instance

Insurance contract or identification number	12701658
Number of Individuals Covered	355
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,258
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00366798

Policy instance

Insurance contract or identification number	00366798
Number of Individuals Covered	724
Insurance policy start date	2010-02-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $90,033
Total amount of fees paid to insurance company	USD $28,757
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $934,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9709452

Policy instance

Insurance contract or identification number	9709452
Number of Individuals Covered	630
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,275
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/00001

Policy instance

Insurance contract or identification number	00107792/00001
Number of Individuals Covered	512
Insurance policy start date	2010-02-01
Insurance policy end date	2011-01-31
Total amount of commissions paid to insurance broker	USD $27,584
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,304,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/00003

Policy instance

Insurance contract or identification number	00107792/00003
Number of Individuals Covered	202
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $14,373
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $791,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0002

Policy instance

Insurance contract or identification number	00107792/0002
Number of Individuals Covered	271
Insurance policy start date	2010-02-01
Insurance policy end date	2011-01-31
Total amount of commissions paid to insurance broker	USD $7,030
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $737,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

4393

Policy instance

Insurance contract or identification number	4393
Number of Individuals Covered	585
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,421
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,421
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

MIDWESTERN DENTAL PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 11107 )

Policy contract number

4002

Policy instance

Insurance contract or identification number	4002
Number of Individuals Covered	126
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $663
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $663
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12701658

Policy instance

Insurance contract or identification number	12701658
Number of Individuals Covered	330
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,216
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,216
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

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

Policy contract number

00366798

Policy instance

Insurance contract or identification number	00366798
Number of Individuals Covered	570
Insurance policy start date	2009-02-01
Insurance policy end date	2010-01-31
Total amount of commissions paid to insurance broker	USD $39,236
Total amount of fees paid to insurance company	USD $14,258
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $527,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,864
Amount paid for insurance broker fees	14258
Insurance broker organization code?	3
Insurance broker name	LUCIDO-MORRIS & ASSOC LLC

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/00001

Policy instance

Insurance contract or identification number	00107792/00001
Number of Individuals Covered	483
Insurance policy start date	2009-02-01
Insurance policy end date	2010-01-31
Total amount of commissions paid to insurance broker	USD $18,762
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,630,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,762
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0003

Policy instance

Insurance contract or identification number	00107792/0003
Number of Individuals Covered	204
Insurance policy start date	2009-02-01
Insurance policy end date	2010-01-31
Total amount of commissions paid to insurance broker	USD $10,855
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $557,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,855
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9709452

Policy instance

Insurance contract or identification number	9709452
Number of Individuals Covered	554
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,883
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,883
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00107792/0002

Policy instance

Insurance contract or identification number	00107792/0002
Number of Individuals Covered	167
Insurance policy start date	2009-02-01
Insurance policy end date	2010-01-31
Total amount of commissions paid to insurance broker	USD $3,835
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $388,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,835
Insurance broker organization code?	3
Insurance broker name	GROUP ASSOCIATES, INC.

Was this data useful?

If you found the data here useful, PLEASE HELP US. We are a start-up and believe in making information freely available. By linking to us, posting on twitter, facebook and linkedin about us and generally spreading the word, you'll help us to grow. Our vision is to provide high quality data about the activities of all the companies in the world and where possible make it free to use and view. Finding and integrating data from thousands of data sources is time consuming and needs lots of effort. By simply spreading the word about us, you will help us. Please use the share buttons. It will only take a few seconds of your time. Thanks for helping

Information Disclaimer

The information provided on this website is not advice, endorsement or recommendation
The information published is supplied by third parties so we make no warranty on the accuracy, completeness etc. This information is provided "as-is". The information is subject to change as we obtain updates and corrections from the primary information sources.
You are free to use the information for your own personal research on the understanding to do so is at your own risk.

See full terms and conditions

Company Name:	MOELLER MFG. COMPANY LLC
Employer identification number (EIN):	381723023
NAIC Classification:	333610