COLUMBIA PIPELINE GROUP, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan COLUMBIA PIPELINE GROUP LIFE AND MEDICAL BENEFITS PROGRAM
401k plan membership statisitcs for COLUMBIA PIPELINE GROUP LIFE AND MEDICAL BENEFITS PROGRAM
| Measure | Date | Value |
|---|
| 2017 : COLUMBIA PIPELINE GROUP LIFE AND MEDICAL BENEFITS PROGRAM 2017 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2017-12-31 | $0 |
| Total transfer of assets from this plan | 2017-12-31 | $122,792,066 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $5,601,480 |
| Total income from all sources (including contributions) | 2017-12-31 | $43,625,131 |
| Total loss/gain on sale of assets | 2017-12-31 | $0 |
| Total of all expenses incurred | 2017-12-31 | $29,228,360 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-12-31 | $27,111,797 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-12-31 | $26,878,812 |
| Value of total assets at end of year | 2017-12-31 | $0 |
| Value of total assets at beginning of year | 2017-12-31 | $113,996,775 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-12-31 | $2,116,563 |
| Total interest from all sources | 2017-12-31 | $48,443 |
| Total dividends received (eg from common stock, registered investment company shares) | 2017-12-31 | $1,397,843 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2017-12-31 | $1,397,843 |
| Administrative expenses professional fees incurred | 2017-12-31 | $683,135 |
| Was this plan covered by a fidelity bond | 2017-12-31 | Yes |
| Value of fidelity bond cover | 2017-12-31 | $13,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2017-12-31 | Yes |
| Amount of non-exempt transactions with any party-in-interest | 2017-12-31 | $2,028,782 |
| Contributions received from participants | 2017-12-31 | $4,762,742 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2017-12-31 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2017-12-31 | $3,007,271 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2017-12-31 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2017-12-31 | $2,594,635 |
| Other income not declared elsewhere | 2017-12-31 | $-161,824 |
| Administrative expenses (other) incurred | 2017-12-31 | $1,421,609 |
| Liabilities. Value of operating payables at end of year | 2017-12-31 | $0 |
| Liabilities. Value of operating payables at beginning of year | 2017-12-31 | $497,592 |
| Total non interest bearing cash at end of year | 2017-12-31 | $0 |
| Total non interest bearing cash at beginning of year | 2017-12-31 | $521,399 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Value of net income/loss | 2017-12-31 | $14,396,771 |
| Value of net assets at end of year (total assets less liabilities) | 2017-12-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2017-12-31 | $108,395,295 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-12-31 | No |
| Investment advisory and management fees | 2017-12-31 | $11,819 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2017-12-31 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2017-12-31 | $103,618,388 |
| Value of interest in common/collective trusts at end of year | 2017-12-31 | $0 |
| Value of interest in common/collective trusts at beginning of year | 2017-12-31 | $6,849,717 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2017-12-31 | $48,443 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-12-31 | $3,240,681 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2017-12-31 | $6,453,775 |
| Net investment gain or loss from common/collective trusts | 2017-12-31 | $9,008,082 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2017-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-12-31 | No |
| Contributions received in cash from employer | 2017-12-31 | $22,116,070 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2017-12-31 | $23,871,116 |
| Liabilities. Value of benefit claims payable at end of year | 2017-12-31 | $0 |
| Liabilities. Value of benefit claims payable at beginning of year | 2017-12-31 | $2,509,253 |
| Did the plan have assets held for investment | 2017-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-12-31 | Yes |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2017-12-31 | Disclaimer |
| Accountancy firm name | 2017-12-31 | CARON AND BLETZER, PLLC |
| Accountancy firm EIN | 2017-12-31 | 043499945 |
| 2016 : COLUMBIA PIPELINE GROUP LIFE AND MEDICAL BENEFITS PROGRAM 2016 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2016-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $2,612,028 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $1,328,118 |
| Total income from all sources (including contributions) | 2016-12-31 | $29,380,886 |
| Total loss/gain on sale of assets | 2016-12-31 | $0 |
| Total of all expenses incurred | 2016-12-31 | $30,633,848 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-12-31 | $29,615,128 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-12-31 | $21,901,094 |
| Value of total assets at end of year | 2016-12-31 | $112,084,469 |
| Value of total assets at beginning of year | 2016-12-31 | $112,053,521 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-12-31 | $1,018,720 |
| Total interest from all sources | 2016-12-31 | $5,627,863 |
| Total dividends received (eg from common stock, registered investment company shares) | 2016-12-31 | $1,851,929 |
| Administrative expenses professional fees incurred | 2016-12-31 | $1,018,720 |
| Was this plan covered by a fidelity bond | 2016-12-31 | No |
| Value of fidelity bond cover | 2016-12-31 | $13,000,000 |
| If this is an individual account plan, was there a blackout period | 2016-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2016-12-31 | No |
| Contributions received from participants | 2016-12-31 | $5,223,047 |
| Assets. Other investments not covered elsewhere at end of year | 2016-12-31 | $1,094,965 |
| Assets. Other investments not covered elsewhere at beginning of year | 2016-12-31 | $347,349 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2016-12-31 | $42,522 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2016-12-31 | $3,007,271 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2016-12-31 | $347,349 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2016-12-31 | $102,775 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2016-12-31 | $302,838 |
| Administrative expenses (other) incurred | 2016-12-31 | $2,669,058 |
| Liabilities. Value of operating payables at end of year | 2016-12-31 | $497,592 |
| Liabilities. Value of operating payables at beginning of year | 2016-12-31 | $201,280 |
| Total non interest bearing cash at end of year | 2016-12-31 | $521,399 |
| Total non interest bearing cash at beginning of year | 2016-12-31 | $3,831,362 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Value of net income/loss | 2016-12-31 | $-1,252,962 |
| Value of net assets at end of year (total assets less liabilities) | 2016-12-31 | $109,472,441 |
| Value of net assets at beginning of year (total assets less liabilities) | 2016-12-31 | $110,725,403 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-12-31 | No |
| Investment advisory and management fees | 2016-12-31 | $15,279 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2016-12-31 | $103,618,388 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2016-12-31 | $101,366,843 |
| Value of interest in common/collective trusts at end of year | 2016-12-31 | $6,849,717 |
| Value of interest in common/collective trusts at beginning of year | 2016-12-31 | $6,507,967 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2016-12-31 | $5,627,863 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-12-31 | $3,162,685 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2016-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-12-31 | No |
| Contributions received in cash from employer | 2016-12-31 | $16,678,047 |
| Income. Dividends from common stock | 2016-12-31 | $1,851,929 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2016-12-31 | $26,409,921 |
| Asset. Corporate debt instrument debt (other) at end of year | 2016-12-31 | $103,618,388 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2016-12-31 | $101,366,843 |
| Liabilities. Value of benefit claims payable at end of year | 2016-12-31 | $2,509,253 |
| Liabilities. Value of benefit claims payable at beginning of year | 2016-12-31 | $824,000 |
| Did the plan have assets held for investment | 2016-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2016-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2016-12-31 | Disclaimer |
| Accountancy firm name | 2016-12-31 | CARON AND BLETZER, PLLC |
| Accountancy firm EIN | 2016-12-31 | 043499945 |
| 2015 : COLUMBIA PIPELINE GROUP LIFE AND MEDICAL BENEFITS PROGRAM 2015 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2015-12-31 | $0 |
| Total transfer of assets to this plan | 2015-12-31 | $110,570,484 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $1,328,118 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $0 |
| Total income from all sources (including contributions) | 2015-12-31 | $14,602,914 |
| Total loss/gain on sale of assets | 2015-12-31 | $0 |
| Total of all expenses incurred | 2015-12-31 | $14,447,995 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-12-31 | $13,990,646 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-12-31 | $16,286,935 |
| Value of total assets at end of year | 2015-12-31 | $112,053,521 |
| Value of total assets at beginning of year | 2015-12-31 | $0 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-12-31 | $457,349 |
| Total interest from all sources | 2015-12-31 | $-2,750,453 |
| Total dividends received (eg from common stock, registered investment company shares) | 2015-12-31 | $1,066,432 |
| Assets. Real estate other than employer real property at beginning of year | 2015-12-31 | $0 |
| Was this plan covered by a fidelity bond | 2015-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2015-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2015-12-31 | No |
| Contributions received from participants | 2015-12-31 | $2,462,805 |
| Assets. Other investments not covered elsewhere at end of year | 2015-12-31 | $347,349 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2015-12-31 | $335,128 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2015-12-31 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2015-12-31 | $302,838 |
| Administrative expenses (other) incurred | 2015-12-31 | $457,349 |
| Liabilities. Value of operating payables at end of year | 2015-12-31 | $201,280 |
| Total non interest bearing cash at end of year | 2015-12-31 | $3,831,362 |
| Total non interest bearing cash at beginning of year | 2015-12-31 | $0 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Value of net income/loss | 2015-12-31 | $154,919 |
| Value of net assets at end of year (total assets less liabilities) | 2015-12-31 | $110,725,403 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-12-31 | No |
| Value of interest in common/collective trusts at end of year | 2015-12-31 | $6,507,967 |
| Value of interest in common/collective trusts at beginning of year | 2015-12-31 | $0 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2015-12-31 | $-2,750,453 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-12-31 | $2,741,644 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2015-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-12-31 | No |
| Contributions received in cash from employer | 2015-12-31 | $13,824,130 |
| Employer contributions (assets) at beginning of year | 2015-12-31 | $0 |
| Income. Dividends from common stock | 2015-12-31 | $1,066,432 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-12-31 | $10,913,874 |
| Asset. Corporate debt instrument debt (other) at end of year | 2015-12-31 | $101,366,843 |
| Liabilities. Value of benefit claims payable at end of year | 2015-12-31 | $824,000 |
| Did the plan have assets held for investment | 2015-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-12-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2015-12-31 | Disclaimer |
| Accountancy firm name | 2015-12-31 | DELOITTE AND TOUCHE LLP |
| Accountancy firm EIN | 2015-12-31 | 133891517 |
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34427-G/34428-G |
| Policy instance | 1 |
| Insurance contract or identification number | 34427-G/34428-G | | Number of Individuals Covered | 3679 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $17,389 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $772,906 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 17389 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 3320032 |
| Policy instance | 2 |
| Insurance contract or identification number | 3320032 | | Number of Individuals Covered | 5832 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,251,346 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 ) |
| Policy contract number | 34427-G/34428-G |
| Policy instance | 1 |
| Insurance contract or identification number | 34427-G/34428-G | | Number of Individuals Covered | 7480 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $51,840 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,036,800 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $51,840 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRIFF SEIBELS AND WILLIAMS OF TX |
|
| KAISER FOUNDATION HEALTH PLAN OF OHIO (National Association of Insurance Commissioners NAIC id number: 95204 ) |
| Policy contract number | 11799 |
| Policy instance | 2 |
| Insurance contract or identification number | 11799 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2015-07-01 | | 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 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,095 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHAMERICA OF PENNSYLVANIA, INC. HMO (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 5926680000 |
| Policy instance | 3 |
| Insurance contract or identification number | 5926680000 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2015-07-01 | | 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 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $673,588 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 525818 |
| Policy instance | 4 |
| Insurance contract or identification number | 525818 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $576 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $34,015 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $576 | | Insurance broker organization code? | 3 | | Insurance broker name | HEWITT INSURANCE BROKERAGE |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 525818 |
| Policy instance | 5 |
| Insurance contract or identification number | 525818 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2015-07-01 | | 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 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,130 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 3320032 |
| Policy instance | 6 |
| Insurance contract or identification number | 3320032 | | Number of Individuals Covered | 6209 | | Insurance policy start date | 2015-07-01 | | 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 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $858,091 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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