METROMEDIA COMPANY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan METROMEDIA COMPANY HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2015: METROMEDIA COMPANY HEALTH AND WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 163 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 13 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 30 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 9 |
| Total of all active and inactive participants | 2015-01-01 | 52 |
| 2014: METROMEDIA COMPANY HEALTH AND WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 153 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 125 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 38 |
| Total of all active and inactive participants | 2014-01-01 | 163 |
| 2013: METROMEDIA COMPANY HEALTH AND WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 158 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 113 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 40 |
| Total of all active and inactive participants | 2013-01-01 | 153 |
| 2012: METROMEDIA COMPANY HEALTH AND WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 165 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 119 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 39 |
| Total of all active and inactive participants | 2012-01-01 | 158 |
| 2011: METROMEDIA COMPANY HEALTH AND WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 170 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 119 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 46 |
| Total of all active and inactive participants | 2011-01-01 | 165 |
| 2009: METROMEDIA COMPANY HEALTH AND WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 208 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 133 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 56 |
| Total of all active and inactive participants | 2009-01-01 | 189 |
| Measure | Date | Value |
|---|
| 2011 : METROMEDIA COMPANY HEALTH AND WELFARE PLAN 2011 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-12-31 | No |
| Was this plan covered by a fidelity bond | 2011-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2011-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-12-31 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2011-12-31 | No |
| Did the plan have assets held for investment | 2011-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-12-31 | No |
| 2010 : METROMEDIA COMPANY HEALTH AND WELFARE PLAN 2010 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2010-12-31 | No |
| Was this plan covered by a fidelity bond | 2010-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2010-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2010-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2010-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2010-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2010-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2010-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2010-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2010-12-31 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2010-12-31 | No |
| Did the plan have assets held for investment | 2010-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2010-12-31 | No |
| FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 ) |
| Policy contract number | LTD 121426 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 121426 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,406 | | Total amount of fees paid to insurance company | USD $84 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,751 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,406 | | Amount paid for insurance broker fees | 84 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| NIAGARA LIFE & HEALTH INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 12285 ) |
| Policy contract number | 417010410859 |
| Policy instance | 5 |
| Insurance contract or identification number | 417010410859 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $8,430 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $176,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,430 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LAKESHORE BENEFIT GROUP INSURANCE B |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 299403 |
| Policy instance | 4 |
| Insurance contract or identification number | 299403 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $7,151 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $35,753 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,151 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | UHY EMPLOYEE BENEFITS CONSULTING |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 299404 |
| Policy instance | 3 |
| Insurance contract or identification number | 299404 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $10,700 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $53,500 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,700 | | Insurance broker organization code? | 3 | | Insurance broker name | UHY EMPLOYEE BENEFITS CONSULTING |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP 9100987-B |
| Policy instance | 2 |
| Insurance contract or identification number | GTP 9100987-B | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $250 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | TRAVEL & ACCIDENT INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $1,000 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $250 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 299403 |
| Policy instance | 4 |
| Insurance contract or identification number | 299403 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $7,232 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,158 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,232 | | Insurance broker organization code? | 3 | | Insurance broker name | UHY EMPLOYEE BENEFITS CONSULTING |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 299404 |
| Policy instance | 3 |
| Insurance contract or identification number | 299404 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $10,817 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,087 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,817 | | Insurance broker organization code? | 3 | | Insurance broker name | UHY EMPLOYEE BENEFITS CONSULTING |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP 9100987-A |
| Policy instance | 2 |
| Insurance contract or identification number | GTP 9100987-A | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $300 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | TRAVEL & ACCIDENT INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $1,500 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $300 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 ) |
| Policy contract number | LTD 121426 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 121426 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $2,426 | | Total amount of fees paid to insurance company | USD $86 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,750 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,426 | | Amount paid for insurance broker fees | 86 | | Insurance broker organization code? | 3 | | Insurance broker name | UHY EMPLOYEE BENEFITS CONSULTING |
|
| NIAGARA LIFE & HEALTH INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 12285 ) |
| Policy contract number | 417009410859 |
| Policy instance | 5 |
| Insurance contract or identification number | 417009410859 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $7,673 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $161,020 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,673 | | Insurance broker organization code? | 3 | | Insurance broker name | LAKESHORE BENEFIT GROUP INSURANCE B |
|
| NIAGARA LIFE & HEALTH INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 12285 ) |
| Policy contract number | 417009410859 |
| Policy instance | 5 |
| Insurance contract or identification number | 417009410859 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $4,866 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $124,836 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,866 | | Insurance broker organization code? | 3 | | Insurance broker name | LAKESHORE BENEFIT GROUP INSURANCE B |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 299403 |
| Policy instance | 4 |
| Insurance contract or identification number | 299403 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $7,488 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,572 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,488 | | Insurance broker organization code? | 3 | | Insurance broker name | UHY EMPLOYEE BENEFITS CONSULTING |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP 9100987-A |
| Policy instance | 2 |
| Insurance contract or identification number | GTP 9100987-A | | Number of Individuals Covered | 145 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $300 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | TRAVEL & ACCIDENT INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $1,500 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $300 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 ) |
| Policy contract number | LTD 121426 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 121426 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $2,469 | | Total amount of fees paid to insurance company | USD $88 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,469 | | Amount paid for insurance broker fees | 88 | | Insurance broker organization code? | 3 | | Insurance broker name | UHY EMPLOYEE BENEFITS CONSULTING |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 299404 |
| Policy instance | 3 |
| Insurance contract or identification number | 299404 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $7,722 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,718 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,722 | | Insurance broker organization code? | 3 | | Insurance broker name | UHY EMPLOYEE BENEFITS CONSULTING |
|
| FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 ) |
| Policy contract number | LTD 121426 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 121426 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,514 | | Total amount of fees paid to insurance company | USD $597 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,499 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,514 | | Amount paid for insurance broker fees | 597 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26921 ) |
| Policy contract number | 417004410859 |
| Policy instance | 5 |
| Insurance contract or identification number | 417004410859 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $5,935 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $118,644 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,935 | | Insurance broker organization code? | 3 | | Insurance broker name | LAKESHORE BENEFIT GROUP INS BROK LL |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 299403 |
| Policy instance | 4 |
| Insurance contract or identification number | 299403 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $6,331 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,524 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,331 | | Insurance broker organization code? | 3 | | Insurance broker name | UHY EMPLOYEE BENEFITS CONSULTING |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 299404 |
| Policy instance | 3 |
| Insurance contract or identification number | 299404 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $6,734 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,564 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,734 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | UHY EMPLOYEE BENEFITS CONSULTING |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP 9100987-A |
| Policy instance | 2 |
| Insurance contract or identification number | GTP 9100987-A | | Number of Individuals Covered | 151 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $300 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | TRAVEL & ACCIDENT INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $1,500 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $300 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 299403 |
| Policy instance | 5 |
| Insurance contract or identification number | 299403 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $4,506 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $22,532 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 299404 |
| Policy instance | 4 |
| Insurance contract or identification number | 299404 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $5,242 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $26,208 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP 9100987-A |
| Policy instance | 3 |
| Insurance contract or identification number | GTP 9100987-A | | Number of Individuals Covered | 48 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $902 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | TRAVEL & ACCIDENT INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $4,508 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 097891 |
| Policy instance | 2 |
| Insurance contract or identification number | LTD 097891 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $2,600 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,389 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 04040 |
| Policy instance | 1 |
| Insurance contract or identification number | 04040 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $9,498 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $47,491 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 417004410859 |
| Policy instance | 6 |
| Insurance contract or identification number | 417004410859 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $7,003 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $139,525 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 097891 |
| Policy instance | 2 |
| Insurance contract or identification number | LTD 097891 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $2,218 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,790 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,218 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 04040 |
| Policy instance | 1 |
| Insurance contract or identification number | 04040 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $28,357 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $141,783 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,357 | | Insurance broker organization code? | 3 | | Insurance broker name | UHY EMPLOYEE BENEFITS CONSULTING |
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| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP 9100987-A |
| Policy instance | 3 |
| Insurance contract or identification number | GTP 9100987-A | | Number of Individuals Covered | 48 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $902 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | TRAVEL & ACCIDENT INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $4,508 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $902 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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