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DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 401k Plan overview

Plan NameDEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH
Plan identification number 501

DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH Benefits

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

401k Sponsoring company profile

DEVENS TREATMENT & RECOVERY CENTER, LLC has sponsored the creation of one or more 401k plans.

Company Name:DEVENS TREATMENT & RECOVERY CENTER, LLC
Employer identification number (EIN):475245366
NAIC Classification:621420
NAIC Description:Outpatient Mental Health and Substance Abuse Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012023-01-01MIRIAM ECHEVARRIA2024-04-04
5012022-01-01MIRIAM ECHEVARRIA2023-07-26
5012021-01-01
5012020-01-01
5012019-10-01
5012018-01-01
5012017-10-01SUSAN COUGHLIN2019-05-28

Plan Statistics for DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH

401k plan membership statisitcs for DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH

Measure Date Value
2023: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2023 401k membership
Total participants, beginning-of-year2023-01-01450
Total number of active participants reported on line 7a of the Form 55002023-01-01408
Number of retired or separated participants receiving benefits2023-01-011
Number of other retired or separated participants entitled to future benefits2023-01-010
Total of all active and inactive participants2023-01-01409
2022: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2022 401k membership
Total participants, beginning-of-year2022-01-01261
Total number of active participants reported on line 7a of the Form 55002022-01-01450
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01450
2021: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2021 401k membership
Total participants, beginning-of-year2021-01-01106
Total number of active participants reported on line 7a of the Form 55002021-01-01261
Total of all active and inactive participants2021-01-01261
Total participants2021-01-01261
2020: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2020 401k membership
Total participants, beginning-of-year2020-01-01270
Total number of active participants reported on line 7a of the Form 55002020-01-01106
Total of all active and inactive participants2020-01-01106
Total participants2020-01-01106
2019: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2019 401k membership
Total participants, beginning-of-year2019-10-01215
Total number of active participants reported on line 7a of the Form 55002019-10-01108
Total of all active and inactive participants2019-10-01108
Total participants2019-10-01108
2018: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2018 401k membership
Total participants, beginning-of-year2018-01-01270
Total number of active participants reported on line 7a of the Form 55002018-01-01215
Total of all active and inactive participants2018-01-01215
Total participants2018-01-01215
2017: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2017 401k membership
Total participants, beginning-of-year2017-10-01122
Total number of active participants reported on line 7a of the Form 55002017-10-01270
Number of retired or separated participants receiving benefits2017-10-010
Number of other retired or separated participants entitled to future benefits2017-10-010
Total of all active and inactive participants2017-10-01270
Number of employers contributing to the scheme2017-10-010

Form 5500 Responses for DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH

2023: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2023 form 5500 responses
2023-01-01Type of plan entitySingle employer plan
2023-01-01Submission has been amendedNo
2023-01-01This submission is the final filingNo
2023-01-01This return/report is a short plan year return/report (less than 12 months)No
2023-01-01Plan is a collectively bargained planNo
2023-01-01Plan funding arrangement – InsuranceYes
2023-01-01Plan funding arrangement – General assets of the sponsorYes
2023-01-01Plan benefit arrangement – InsuranceYes
2023-01-01Plan benefit arrangement – General assets of the sponsorYes
2022: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Submission has been amendedNo
2019-10-01This submission is the final filingNo
2019-10-01This return/report is a short plan year return/report (less than 12 months)Yes
2019-10-01Plan is a collectively bargained planNo
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan funding arrangement – General assets of the sponsorYes
2019-10-01Plan benefit arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – General assets of the sponsorYes
2018: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2018 form 5500 responses
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: DEVENS TREATMENT & RECOVERY CENTER LLC, DBA TARA VISTA BEHAVIORAL HEALTH 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01First time form 5500 has been submittedYes
2017-10-01Plan funding arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30070223
Policy instance 2
Insurance contract or identification number30070223
Number of Individuals Covered219
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $1,739
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $24,304
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 number00025765
Policy instance 1
Insurance contract or identification number00025765
Number of Individuals Covered408
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $29,907
Total amount of fees paid to insurance companyUSD $6,960
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, ACCIDENT, VOLUNTARY CRITICAL ILLNESS
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 CarrierUSD $458,296
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 number30070223
Policy instance 2
Insurance contract or identification number30070223
Number of Individuals Covered241
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,568
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $25,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $943
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00025765
Policy instance 1
Insurance contract or identification number00025765
Number of Individuals Covered450
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $31,183
Total amount of fees paid to insurance companyUSD $73
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, ACCIDENT & CRITICAL ILLNESS
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 CarrierUSD $512,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31,183
Amount paid for insurance broker fees73
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
Policy contract number21ANO1B640
Policy instance 5
Insurance contract or identification number21ANO1B640
Number of Individuals Covered261
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $677,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURAQNCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number25765
Policy instance 4
Insurance contract or identification number25765
Number of Individuals Covered490
Insurance policy start date2021-09-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $87,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number014222
Policy instance 3
Insurance contract or identification number014222
Number of Individuals Covered0
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,380
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $123,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,380
Amount paid for insurance broker fees0
Insurance broker organization code?3
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 52411 )
Policy contract number45774
Policy instance 2
Insurance contract or identification number45774
Number of Individuals Covered360
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $7,751
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $133,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,751
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30070223
Policy instance 1
Insurance contract or identification number30070223
Number of Individuals Covered218
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $838
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $17,846
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $838
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30070223
Policy instance 4
Insurance contract or identification number30070223
Number of Individuals Covered102
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,004
Total amount of fees paid to insurance companyUSD $109
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $11,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees109
Insurance broker organization code?3
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 52411 )
Policy contract number45774
Policy instance 3
Insurance contract or identification number45774
Number of Individuals Covered234
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $9,120
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $146,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,120
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number014222
Policy instance 2
Insurance contract or identification number014222
Number of Individuals Covered240
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $4,076
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $107,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,076
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
Policy contract number20ANO1B539
Policy instance 1
Insurance contract or identification number20ANO1B539
Number of Individuals Covered106
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $480,402
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 number30070223
Policy instance 5
Insurance contract or identification number30070223
Number of Individuals Covered99
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $692
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SECURITY MUTUAL LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 68772 )
Policy contract numberGRP035343
Policy instance 4
Insurance contract or identification numberGRP035343
Number of Individuals Covered211
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $12,562
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $89,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
FALLON HEALTH AND LIFE INSURANCE COMPANY - FHLAC (National Association of Insurance Commissioners NAIC id number: 66828 )
Policy contract numberC004517297C01
Policy instance 3
Insurance contract or identification numberC004517297C01
Number of Individuals Covered16
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $2,168
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $73,742
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
FALLON COMMUNITY HEALTH PLAN -MEDICARE (National Association of Insurance Commissioners NAIC id number: 95541 )
Policy contract numberC004517297C01
Policy instance 2
Insurance contract or identification numberC004517297C01
Number of Individuals Covered190
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $18,668
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $640,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number14222
Policy instance 1
Insurance contract or identification number14222
Number of Individuals Covered214
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $4,438
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $102,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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