RRR BOWIE LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN
| 2023: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2023 form 5500 responses |
|---|
| 2023-05-01 | Type of plan entity | Multi-employer plan |
| 2023-05-01 | Plan is a collectively bargained plan | Yes |
| 2023-05-01 | Plan funding arrangement – Insurance | Yes |
| 2023-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-05-01 | Type of plan entity | Multi-employer plan |
| 2022-05-01 | Plan is a collectively bargained plan | Yes |
| 2022-05-01 | Plan funding arrangement – Insurance | Yes |
| 2022-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-05-01 | Type of plan entity | Multi-employer plan |
| 2021-05-01 | Plan is a collectively bargained plan | Yes |
| 2021-05-01 | Plan funding arrangement – Insurance | Yes |
| 2021-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-05-01 | Type of plan entity | Multi-employer plan |
| 2020-05-01 | Plan is a collectively bargained plan | Yes |
| 2020-05-01 | Plan funding arrangement – Insurance | Yes |
| 2020-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-05-01 | Type of plan entity | Multi-employer plan |
| 2019-05-01 | Plan funding arrangement – Insurance | Yes |
| 2019-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-05-01 | Type of plan entity | Multi-employer plan |
| 2018-05-01 | Plan funding arrangement – Insurance | Yes |
| 2018-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-05-01 | Type of plan entity | Multi-employer plan |
| 2017-05-01 | Plan funding arrangement – Insurance | Yes |
| 2017-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-05-01 | Type of plan entity | Multi-employer plan |
| 2016-05-01 | Submission has been amended | No |
| 2016-05-01 | This submission is the final filing | No |
| 2016-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-05-01 | Plan is a collectively bargained plan | No |
| 2016-05-01 | Plan funding arrangement – Insurance | Yes |
| 2016-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-05-01 | Type of plan entity | Multi-employer plan |
| 2015-05-01 | Submission has been amended | No |
| 2015-05-01 | This submission is the final filing | No |
| 2015-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-05-01 | Plan is a collectively bargained plan | No |
| 2015-05-01 | Plan funding arrangement – Insurance | Yes |
| 2015-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-05-01 | Type of plan entity | Multi-employer plan |
| 2014-05-01 | Submission has been amended | No |
| 2014-05-01 | This submission is the final filing | No |
| 2014-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-05-01 | Plan is a collectively bargained plan | No |
| 2014-05-01 | Plan funding arrangement – Insurance | Yes |
| 2014-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-05-01 | Type of plan entity | Multi-employer plan |
| 2013-05-01 | Submission has been amended | No |
| 2013-05-01 | This submission is the final filing | No |
| 2013-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-05-01 | Plan is a collectively bargained plan | No |
| 2013-05-01 | Plan funding arrangement – Insurance | Yes |
| 2013-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-05-01 | Type of plan entity | Multi-employer plan |
| 2012-05-01 | Submission has been amended | No |
| 2012-05-01 | This submission is the final filing | No |
| 2012-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-05-01 | Plan is a collectively bargained plan | No |
| 2012-05-01 | Plan funding arrangement – Insurance | Yes |
| 2012-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-05-01 | Type of plan entity | Multi-employer plan |
| 2011-05-01 | Submission has been amended | No |
| 2011-05-01 | This submission is the final filing | No |
| 2011-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-05-01 | Plan is a collectively bargained plan | No |
| 2011-05-01 | Plan funding arrangement – Insurance | Yes |
| 2011-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-05-01 | Type of plan entity | Multi-employer plan |
| 2010-05-01 | Submission has been amended | No |
| 2010-05-01 | This submission is the final filing | No |
| 2010-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-05-01 | Plan is a collectively bargained plan | No |
| 2010-05-01 | Plan funding arrangement – Insurance | Yes |
| 2010-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-05-01 | Type of plan entity | Multi-employer plan |
| 2009-05-01 | Submission has been amended | No |
| 2009-05-01 | This submission is the final filing | No |
| 2009-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-05-01 | Plan is a collectively bargained plan | No |
| 2009-05-01 | Plan funding arrangement – Insurance | Yes |
| 2009-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2008 form 5500 responses |
|---|
| 2008-05-01 | Type of plan entity | Multi-employer plan |
| 2008-05-01 | Submission has been amended | No |
| 2008-05-01 | This submission is the final filing | No |
| 2008-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-05-01 | Plan is a collectively bargained plan | No |
| 2008-05-01 | Plan funding arrangement – Insurance | Yes |
| 2008-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2007: RRR BOWIE, LLC EMPLOYEE HEALTH BENEFIT PLAN 2007 form 5500 responses |
|---|
| 2007-05-01 | Type of plan entity | Multi-employer plan |
| 2007-05-01 | First time form 5500 has been submitted | Yes |
| 2007-05-01 | Submission has been amended | No |
| 2007-05-01 | This submission is the final filing | No |
| 2007-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-05-01 | Plan is a collectively bargained plan | No |
| 2007-05-01 | Plan funding arrangement – Insurance | Yes |
| 2007-05-01 | Plan benefit arrangement – Insurance | Yes |
| BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 ) |
| Policy contract number | 52815 |
| Policy instance | 5 |
| Insurance contract or identification number | 52815 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $35,109 | | Total amount of fees paid to insurance company | USD $0 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $197,634 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 27461 |
| Policy instance | 4 |
| Insurance contract or identification number | 27461 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | Total amount of commissions paid to insurance broker | USD $229 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $3,052 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 149217HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 149217HNO | | Number of Individuals Covered | 10 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | Total amount of commissions paid to insurance broker | USD $33,974 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,527,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 149217 |
| Policy instance | 2 |
| Insurance contract or identification number | 149217 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | Total amount of commissions paid to insurance broker | USD $14,696 | | Total amount of fees paid to insurance company | USD $209 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $141,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| INOVA EMPLOYEE ASSISTANCE (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | EAP |
| Policy instance | 1 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 584 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $7,755 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| INOVA EMPLOYEE ASSISTANCE (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | EAP |
| Policy instance | 1 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 465 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $7,031 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 27461 |
| Policy instance | 2 |
| Insurance contract or identification number | 27461 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $295 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $3,932 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 ) |
| Policy contract number | 52815 |
| Policy instance | 3 |
| Insurance contract or identification number | 52815 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $41,490 | | Total amount of fees paid to insurance company | USD $0 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $229,718 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 149217 |
| Policy instance | 4 |
| Insurance contract or identification number | 149217 | | Number of Individuals Covered | 410 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $46,897 | | Total amount of fees paid to insurance company | USD $35,940 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | 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 $1,840,257 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| INOVA EMPLOYEE ASSISTANCE (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | EAP |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 149217 |
| Policy instance | 2 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 149217HNO |
| Policy instance | 3 |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 27461 |
| Policy instance | 4 |
| BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 ) |
| Policy contract number | 52815 |
| Policy instance | 5 |
| INOVA EMPLOYEE ASSISTANCE (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | EAP |
| Policy instance | 1 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 917541 |
| Policy instance | 2 |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 27461 |
| Policy instance | 3 |
| BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 ) |
| Policy contract number | 54663 |
| Policy instance | 4 |
| INOVA EMPLOYEE ASSISTANCE (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | EAP |
| Policy instance | 1 |
| BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 ) |
| Policy contract number | 54663 |
| Policy instance | 2 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 917541 |
| Policy instance | 3 |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 27461 |
| Policy instance | 4 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30067073 |
| Policy instance | 1 |
| INOVA EMPLOYEE ASSISTANCE (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | EAP |
| Policy instance | 2 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 450631 |
| Policy instance | 3 |
| BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 ) |
| Policy contract number | 54663 |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 4506331HNO |
| Policy instance | 5 |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 27460 |
| Policy instance | 6 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30067073 |
| Policy instance | 1 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 49569 |
| Policy instance | 3 |
| INOVA EMPLOYEE ASSISTANCE (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | EAP |
| Policy instance | 2 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 450631 |
| Policy instance | 4 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 49864 |
| Policy instance | 5 |
| BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 ) |
| Policy contract number | 54663 |
| Policy instance | 6 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 4506331HNO |
| Policy instance | 8 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30067073 |
| Policy instance | 7 |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 29567 |
| Policy instance | 9 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 705643 |
| Policy instance | 5 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 49569/49864 |
| Policy instance | 4 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 8060/36458 |
| Policy instance | 3 |
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 22059 |
| Policy instance | 2 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05129072 |
| Policy instance | 1 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 705643 |
| Policy instance | 5 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 49569/49864 |
| Policy instance | 4 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 8060/36458 |
| Policy instance | 3 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05129072 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 22059 |
| Policy instance | 2 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05129072 |
| Policy instance | 1 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 8060/36458 |
| Policy instance | 3 |
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 22059 |
| Policy instance | 2 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 49569/49864 |
| Policy instance | 4 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 705643 |
| Policy instance | 5 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05129072 |
| Policy instance | 1 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 705643 |
| Policy instance | 2 |
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 22059 |
| Policy instance | 3 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 79413 |
| Policy instance | 4 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 8060/36458 |
| Policy instance | 5 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 49569/49864 |
| Policy instance | 6 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 705643 |
| Policy instance | 2 |
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | 17J4 |
| Policy instance | 3 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 8060/36458 |
| Policy instance | 4 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 49569/49864 |
| Policy instance | 5 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05129072 |
| Policy instance | 1 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 8060/36458 |
| Policy instance | 4 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 705643 |
| Policy instance | 2 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05129072 |
| Policy instance | 1 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 49569/49864 |
| Policy instance | 5 |
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | 17J4 |
| Policy instance | 3 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05129072 |
| Policy instance | 1 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 705643 |
| Policy instance | 2 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 8060/36458 |
| Policy instance | 3 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 49569/49864 |
| Policy instance | 4 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 8060/36458 |
| Policy instance | 3 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 49569/49864 |
| Policy instance | 4 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 705643 |
| Policy instance | 2 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05129072 |
| Policy instance | 1 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05129072 |
| Policy instance | 1 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 49569/49864 |
| Policy instance | 4 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 806036458 |
| Policy instance | 3 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 705643 |
| Policy instance | 2 |
