401k Plan data: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN plan

EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN
Plan identification number	510

EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover

401k Sponsoring company profile

EXCALIBUR YOUTH SERVICE, LLC has sponsored the creation of one or more 401k plans.

Company Name: EXCALIBUR YOUTH SERVICE, LLC

Employer identification number (EIN): 571105666

NAIC Classification: 561210
NAIC Description: Facilities Support Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
510 2021-01-01
510 2020-01-01
510 2019-01-01
510 2018-01-01
510 2017-01-01 MARVIN J. SHORT III
510 2016-01-01 MARVIN J. SHORT III
510 2015-01-01 MARVIN J. SHORT III
510 2014-01-01 MARVIN J. SHORT III
510 2013-01-01 MARVIN J. SHORT III
510 2012-01-01 MARVIN J. SHORT III
510 2011-01-01 MARVIN J. SHORT III
510 2009-01-01 MARVIN J. SHORT III

Plan Statistics for EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN

401k plan membership statisitcs for EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN

Measure Date Value
2021: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 287
Total of all active and inactive participants 2021-01-01 0
Total participants 2021-01-01 0
2020: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 265
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 287
Total of all active and inactive participants 2020-01-01 287
Total participants 2020-01-01 287
2019: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 261
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 265
Total of all active and inactive participants 2019-01-01 265
Total participants 2019-01-01 265
2018: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 233
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 261
Total of all active and inactive participants 2018-01-01 261
Total participants 2018-01-01 261
2017: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 288
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 233
Number of retired or separated participants receiving benefits 2017-01-01 233
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 466
2016: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 273
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 288
Number of retired or separated participants receiving benefits 2016-01-01 288
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 576
2015: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 246
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 273
Number of retired or separated participants receiving benefits 2015-01-01 273
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 546
2014: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 199
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 246
Number of retired or separated participants receiving benefits 2014-01-01 246
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 492
2013: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 339
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 199
Total of all active and inactive participants 2013-01-01 199
2012: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 485
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 339
Total of all active and inactive participants 2012-01-01 339
2011: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 172
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 485
Total of all active and inactive participants 2011-01-01 485
2009: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 171
Total of all active and inactive participants 2009-01-01 171

Measure	Date	Value
2021: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	287
Total of all active and inactive participants	2021-01-01	0
Total participants	2021-01-01	0
2020: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	265
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	287
Total of all active and inactive participants	2020-01-01	287
Total participants	2020-01-01	287
2019: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	261
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	265
Total of all active and inactive participants	2019-01-01	265
Total participants	2019-01-01	265
2018: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	233
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	261
Total of all active and inactive participants	2018-01-01	261
Total participants	2018-01-01	261
2017: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	288
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	233
Number of retired or separated participants receiving benefits	2017-01-01	233
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	466
2016: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	273
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	288
Number of retired or separated participants receiving benefits	2016-01-01	288
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	576
2015: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	246
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	273
Number of retired or separated participants receiving benefits	2015-01-01	273
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	546
2014: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	199
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	246
Number of retired or separated participants receiving benefits	2014-01-01	246
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	492
2013: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	339
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	199
Total of all active and inactive participants	2013-01-01	199
2012: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	485
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	339
Total of all active and inactive participants	2012-01-01	339
2011: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	172
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	485
Total of all active and inactive participants	2011-01-01	485
2009: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	171
Total of all active and inactive participants	2009-01-01	171

Form 5500 Responses for EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN

2021: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	This submission is the final filing	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: EXCALIBUR YOUTH SERVICES LLC EMPLOYEE WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	First time form 5500 has been submitted	Yes
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

944963

Policy instance

Insurance contract or identification number	944963
Number of Individuals Covered	14
Total amount of commissions paid to insurance broker	USD $754
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $633
Insurance broker organization code?	3

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

00254

Policy instance

Insurance contract or identification number	00254
Number of Individuals Covered	133
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $56,271
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,987
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

936718

Policy instance

Insurance contract or identification number	936718
Number of Individuals Covered	207
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,579
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
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 $75,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,953
Insurance broker organization code?	3

PHYSICIANS EYECARE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

00505

Policy instance

Insurance contract or identification number	00505
Number of Individuals Covered	148
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,597
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,505
Insurance broker organization code?	3

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

Policy contract number

00555180

Policy instance

Insurance contract or identification number	00555180
Number of Individuals Covered	217
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $43,022
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, ACCIDENT
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 $243,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,658
Insurance broker organization code?	3

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

00254

Policy instance

Insurance contract or identification number	00254
Number of Individuals Covered	174
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $54,850
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,850

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

00555180

Policy instance

Insurance contract or identification number	00555180
Number of Individuals Covered	287
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,144
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $719

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

03-07656

Policy instance

Insurance contract or identification number	03-07656
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

00555180

Policy instance

Insurance contract or identification number	00555180
Number of Individuals Covered	265
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $124,575
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $120,075

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

00254

Policy instance

Insurance contract or identification number	00254
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $120,075
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $120,075

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

00254

Policy instance

Insurance contract or identification number	00254
Number of Individuals Covered	160
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $44,429
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,429

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

234046

Policy instance

Insurance contract or identification number	234046
Number of Individuals Covered	261
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $16,910
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,910

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

03-07656

Policy instance

Insurance contract or identification number	03-07656
Number of Individuals Covered	161
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

234046

Policy instance

Insurance contract or identification number	234046
Number of Individuals Covered	233
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $22,780
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $181,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,780
Insurance broker organization code?	3
Insurance broker name	MARK FISCHMAN

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA477

Policy instance

Insurance contract or identification number	BA477
Number of Individuals Covered	152
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $45,017
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,017
Insurance broker name	MARK FISCHMAN

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

234046

Policy instance

Insurance contract or identification number	234046
Number of Individuals Covered	246
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $22,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,143
Insurance broker organization code?	3
Insurance broker name	MARK FISCHMAN

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA477

Policy instance

Insurance contract or identification number	BA477
Number of Individuals Covered	139
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $45,475
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,475
Insurance broker name	MARK FISCHMAN

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA477

Policy instance

Insurance contract or identification number	BA477
Number of Individuals Covered	139
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	MARK FISCHMAN

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

234046

Policy instance

Insurance contract or identification number	234046
Number of Individuals Covered	246
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $18,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,626
Insurance broker organization code?	3
Insurance broker name	MARK FISCHMAN

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

Policy contract number

00443210

Policy instance

Insurance contract or identification number	00443210
Number of Individuals Covered	199
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $20,907
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $162,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,907
Insurance broker name	MARK FISCHMAN

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA477

Policy instance

Insurance contract or identification number	BA477
Number of Individuals Covered	139
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $36,231
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,231
Insurance broker name	MARK FISCHMAN

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA477

Policy instance

Insurance contract or identification number	BA477
Number of Individuals Covered	193
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $36,329
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,329
Insurance broker name	MARK FISCHMAN

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

Policy contract number

00443210

Policy instance

Insurance contract or identification number	00443210
Number of Individuals Covered	243
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $14,052
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $114,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,052
Insurance broker name	MARK FISCHMAN

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0007003978

Policy instance

Insurance contract or identification number	0007003978
Number of Individuals Covered	485
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $12,759
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,759
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	MARK FISHMAN

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0007003978

Policy instance

Insurance contract or identification number	0007003978
Number of Individuals Covered	485
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $42,630
Total amount of fees paid to insurance company	USD $897
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $98,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

095604

Policy instance

Insurance contract or identification number	095604
Number of Individuals Covered	73
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,109
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

115968

Policy instance

Insurance contract or identification number	115968
Number of Individuals Covered	52
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,301
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA477

Policy instance

Insurance contract or identification number	BA477
Number of Individuals Covered	182
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $31,275
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00443210

Policy instance

Insurance contract or identification number	00443210
Number of Individuals Covered	193
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $14,691
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

095604

Policy instance

Insurance contract or identification number	095604
Number of Individuals Covered	52
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,280
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,280
Insurance broker organization code?	3
Insurance broker name	MARK FISCHMAN

BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 )

Policy contract number

BA477

Policy instance

Insurance contract or identification number	BA477
Number of Individuals Covered	168
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $32,811
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,811
Insurance broker organization code?	3
Insurance broker name	MARK FISCHMAN

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

115968

Policy instance

Insurance contract or identification number	115968
Number of Individuals Covered	49
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,578
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,578
Insurance broker organization code?	3
Insurance broker name	MARK FISCHMAN

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

Policy contract number

00443210

Policy instance

Insurance contract or identification number	00443210
Number of Individuals Covered	172
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $12,137
Total amount of fees paid to insurance company	USD $2,131
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $99,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,137
Amount paid for insurance broker fees	2131
Additional information about fees paid to insurance broker	PRODUCER COMISSIONS
Insurance broker organization code?	3
Insurance broker name	MARK FISCHMAN

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Company Name:	EXCALIBUR YOUTH SERVICE, LLC
Employer identification number (EIN):	571105666
NAIC Classification:	561210
NAIC Description:	Facilities Support Services