KCI HOLDING USA, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan KCI HOLDING USA, INC. EMPLOYEE HEALTH CARE PLAN
401k plan membership statisitcs for KCI HOLDING USA, INC. EMPLOYEE HEALTH CARE PLAN
| Measure | Date | Value |
|---|
| 2022 : KCI HOLDING USA, INC. EMPLOYEE HEALTH CARE PLAN 2022 401k financial data |
|---|
| Total income from all sources (including contributions) | 2022-12-31 | $43,386,415 |
| Total of all expenses incurred | 2022-12-31 | $36,980,223 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-12-31 | $34,097,496 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-12-31 | $43,379,130 |
| Value of total assets at end of year | 2022-12-31 | $7,084,530 |
| Value of total assets at beginning of year | 2022-12-31 | $678,338 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2022-12-31 | $2,882,727 |
| Total interest from all sources | 2022-12-31 | $7,285 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-12-31 | No |
| Was this plan covered by a fidelity bond | 2022-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2022-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2022-12-31 | No |
| Contributions received from participants | 2022-12-31 | $3,064,918 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2022-12-31 | $866,051 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2022-12-31 | $678,330 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Value of net income/loss | 2022-12-31 | $6,406,192 |
| Value of net assets at end of year (total assets less liabilities) | 2022-12-31 | $7,084,530 |
| Value of net assets at beginning of year (total assets less liabilities) | 2022-12-31 | $678,338 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2022-12-31 | $6,218,479 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2022-12-31 | $8 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2022-12-31 | $8 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2022-12-31 | $7,285 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2022-12-31 | $2,331,832 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2022-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-12-31 | No |
| Contributions received in cash from employer | 2022-12-31 | $40,314,212 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2022-12-31 | $31,765,664 |
| Contract administrator fees | 2022-12-31 | $2,882,727 |
| Did the plan have assets held for investment | 2022-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2022-12-31 | Unqualified |
| Accountancy firm name | 2022-12-31 | SWINDON, SPRINGER & COMPANY, INC. |
| Accountancy firm EIN | 2022-12-31 | 311339842 |
| 2021 : KCI HOLDING USA, INC. EMPLOYEE HEALTH CARE PLAN 2021 401k financial data |
|---|
| Total income from all sources (including contributions) | 2021-12-31 | $25,859,131 |
| Total of all expenses incurred | 2021-12-31 | $26,013,686 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-12-31 | $23,058,452 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-12-31 | $25,859,123 |
| Value of total assets at end of year | 2021-12-31 | $678,338 |
| Value of total assets at beginning of year | 2021-12-31 | $832,893 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-12-31 | $2,955,234 |
| Total interest from all sources | 2021-12-31 | $8 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-12-31 | No |
| Was this plan covered by a fidelity bond | 2021-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2021-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-12-31 | No |
| Contributions received from participants | 2021-12-31 | $3,110,571 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2021-12-31 | $678,330 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2021-12-31 | $831,893 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Value of net income/loss | 2021-12-31 | $-154,555 |
| Value of net assets at end of year (total assets less liabilities) | 2021-12-31 | $678,338 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-12-31 | $832,893 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2021-12-31 | $8 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2021-12-31 | $1,000 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2021-12-31 | $1,000 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2021-12-31 | $8 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-12-31 | $1,803,429 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-12-31 | No |
| Contributions received in cash from employer | 2021-12-31 | $22,748,552 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-12-31 | $21,255,023 |
| Contract administrator fees | 2021-12-31 | $2,955,234 |
| Did the plan have assets held for investment | 2021-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2021-12-31 | Unqualified |
| Accountancy firm name | 2021-12-31 | SWINDON, SPRINGER & COMPANY, INC. |
| Accountancy firm EIN | 2021-12-31 | 311339842 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97707101001 |
| Policy instance | 2 |
| Insurance contract or identification number | 97707101001 | | Number of Individuals Covered | 4037 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $150,541 | | 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 | GTP0009138099-C |
| Policy instance | 7 |
| Insurance contract or identification number | GTP0009138099-C | | Number of Individuals Covered | 2048 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,411 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $12,056 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,411 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 802561 |
| Policy instance | 6 |
| Insurance contract or identification number | 802561 | | Number of Individuals Covered | 1496 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $102,489 | | Welfare Benefit Premiums Paid to Carrier | USD $566,813 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $79,428 | | Insurance broker organization code? | 3 |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 945418 |
| Policy instance | 5 |
| Insurance contract or identification number | 945418 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | PAID FAMILY LEAVE | | Welfare Benefit Premiums Paid to Carrier | USD $5,770 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 99279631001 |
| Policy instance | 4 |
| Insurance contract or identification number | 99279631001 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,366 | | 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 | 944506 |
| Policy instance | 3 |
| Insurance contract or identification number | 944506 | | Number of Individuals Covered | 2489 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,468,145 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | IISI 3612-22 |
| Policy instance | 1 |
| Insurance contract or identification number | IISI 3612-22 | | Number of Individuals Covered | 2048 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of fees paid to insurance company | USD $68,674 | | Welfare Benefit Premiums Paid to Carrier | USD $981,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 68674 | | Additional information about fees paid to insurance broker | GA FEES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 97707101001 |
| Policy instance | 4 |
| Insurance contract or identification number | 97707101001 | | Number of Individuals Covered | 4038 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $153,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | GF388005444701 |
| Policy instance | 3 |
| Insurance contract or identification number | GF388005444701 | | Number of Individuals Covered | 1971 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of fees paid to insurance company | USD $5,349 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $94,663 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 5349 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| STHEALTH/CHARTIS (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | IISI 3612 |
| Policy instance | 2 |
| Insurance contract or identification number | IISI 3612 | | Number of Individuals Covered | 1737 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Welfare Benefit Premiums Paid to Carrier | USD $497,817 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | SA388005444701 |
| Policy instance | 1 |
| Insurance contract or identification number | SA388005444701 | | Number of Individuals Covered | 1971 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of fees paid to insurance company | USD $12,896 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $233,599 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 12896 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP0009138099-B |
| Policy instance | 11 |
| Insurance contract or identification number | GTP0009138099-B | | Number of Individuals Covered | 1971 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,620 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,802 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,620 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 944506 |
| Policy instance | 5 |
| Insurance contract or identification number | 944506 | | Number of Individuals Covered | 17115 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2021-12-31 | | Total amount of fees paid to insurance company | USD $32,826 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,309,198 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 32826 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | PD388005444703 |
| Policy instance | 7 |
| Insurance contract or identification number | PD388005444703 | | Number of Individuals Covered | 1933 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 945418 |
| Policy instance | 8 |
| Insurance contract or identification number | 945418 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2021-12-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | PAID FAMILY LEAVE | | Welfare Benefit Premiums Paid to Carrier | USD $8,431 | | 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 | 802561 |
| Policy instance | 9 |
| Insurance contract or identification number | 802561 | | Number of Individuals Covered | 1592 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $163,072 | | Welfare Benefit Premiums Paid to Carrier | USD $598,458 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $163,072 | | Insurance broker organization code? | 3 |
|
| ATLANTIC SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 27154 ) |
| Policy contract number | 2170000530000 |
| Policy instance | 10 |
| Insurance contract or identification number | 2170000530000 | | Number of Individuals Covered | 1737 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Welfare Benefit Premiums Paid to Carrier | USD $699,390 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 99279631001 |
| Policy instance | 6 |
| Insurance contract or identification number | 99279631001 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,142 | | 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 | GTP0009138099-B |
| Policy instance | 6 |
| Insurance contract or identification number | GTP0009138099-B | | Number of Individuals Covered | 2026 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,620 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,802 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,620 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 99279631001 |
| Policy instance | 1 |
| Insurance contract or identification number | 99279631001 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 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 $2,364 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | SA388005444701 |
| Policy instance | 2 |
| Insurance contract or identification number | SA388005444701 | | Number of Individuals Covered | 2026 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $5,984 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,040,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 5984 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF388005444701 |
| Policy instance | 3 |
| Insurance contract or identification number | GF388005444701 | | Number of Individuals Covered | 2026 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $2,939 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $437,151 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 2939 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 97707101001 |
| Policy instance | 4 |
| Insurance contract or identification number | 97707101001 | | Number of Individuals Covered | 4178 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 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 $163,768 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 4009992 |
| Policy instance | 5 |
| Insurance contract or identification number | 4009992 | | Number of Individuals Covered | 4444 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,078,764 | | 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 | W1339 |
| Policy instance | 8 |
| Insurance contract or identification number | W1339 | | Number of Individuals Covered | 849 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $74,905 | | Total amount of fees paid to insurance company | USD $5,454 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $319,341 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,555 | | Amount paid for insurance broker fees | 2092 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP0009138099B |
| Policy instance | 7 |
| Insurance contract or identification number | GTP0009138099B | | Number of Individuals Covered | 2464 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,620 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $10,802 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,620 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 97707101001 |
| Policy instance | 5 |
| Insurance contract or identification number | 97707101001 | | Number of Individuals Covered | 4602 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $169,910 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 1496 |
| Policy instance | 6 |
| Insurance contract or identification number | 1496 | | Number of Individuals Covered | 5083 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,527,937 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF388005444701 |
| Policy instance | 4 |
| Insurance contract or identification number | GF388005444701 | | Number of Individuals Covered | 2184 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of fees paid to insurance company | USD $1,777 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $368,785 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1777 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | PD388005444703 |
| Policy instance | 3 |
| Insurance contract or identification number | PD388005444703 | | Number of Individuals Covered | 2140 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 4009992 |
| Policy instance | 2 |
| Insurance contract or identification number | 4009992 | | Number of Individuals Covered | 4766 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Welfare Benefit Premiums Paid to Carrier | USD $1,925,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | SA388005444701 |
| Policy instance | 1 |
| Insurance contract or identification number | SA388005444701 | | Number of Individuals Covered | 2262 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of fees paid to insurance company | USD $2,084 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $804,118 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2760 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 99279631001 |
| Policy instance | 9 |
| Insurance contract or identification number | 99279631001 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,954 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 4009992 |
| Policy instance | 2 |
| Insurance contract or identification number | 4009992 | | Number of Individuals Covered | 4804 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Welfare Benefit Premiums Paid to Carrier | USD $1,610,889 | | 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 | W1339 |
| Policy instance | 8 |
| Insurance contract or identification number | W1339 | | Number of Individuals Covered | 1352 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $208,777 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $405,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $94,101 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 99279631001 |
| Policy instance | 9 |
| Insurance contract or identification number | 99279631001 | | Number of Individuals Covered | 59 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,061 | | 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 0009138099 |
| Policy instance | 7 |
| Insurance contract or identification number | GTP 0009138099 | | Number of Individuals Covered | 2408 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-10-01 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $12,337 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 1496 |
| Policy instance | 6 |
| Insurance contract or identification number | 1496 | | Number of Individuals Covered | 5106 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,524,273 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 97707101001 |
| Policy instance | 5 |
| Insurance contract or identification number | 97707101001 | | Number of Individuals Covered | 4569 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $170,374 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF388005444701 |
| Policy instance | 4 |
| Insurance contract or identification number | GF388005444701 | | Number of Individuals Covered | 2259 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $381,386 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | PD388005444701 |
| Policy instance | 3 |
| Insurance contract or identification number | PD388005444701 | | Number of Individuals Covered | 2259 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | SA388005444701 |
| Policy instance | 1 |
| Insurance contract or identification number | SA388005444701 | | Number of Individuals Covered | 2259 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $783,668 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 97707101001 |
| Policy instance | 5 |
| Insurance contract or identification number | 97707101001 | | Number of Individuals Covered | 4899 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $206,208 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 1496 |
| Policy instance | 6 |
| Insurance contract or identification number | 1496 | | Number of Individuals Covered | 5408 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,452,931 | | 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 0009138099 |
| Policy instance | 7 |
| Insurance contract or identification number | GTP 0009138099 | | Number of Individuals Covered | 3203 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-10-01 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $12,337 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GS388005444701 |
| Policy instance | 8 |
| Insurance contract or identification number | GS388005444701 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,077 | | 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 | W1339 |
| Policy instance | 9 |
| Insurance contract or identification number | W1339 | | Number of Individuals Covered | 328 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $39,969 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $117,241 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,670 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER VOLUNTARY BNFTS LLC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 99279631001 |
| Policy instance | 10 |
| Insurance contract or identification number | 99279631001 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,547 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF388005444701 |
| Policy instance | 4 |
| Insurance contract or identification number | GF388005444701 | | Number of Individuals Covered | 2266 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $435,438 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | PD388005444703 |
| Policy instance | 3 |
| Insurance contract or identification number | PD388005444703 | | Number of Individuals Covered | 2240 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 716251 |
| Policy instance | 2 |
| Insurance contract or identification number | 716251 | | Number of Individuals Covered | 5245 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Welfare Benefit Premiums Paid to Carrier | USD $2,085,020 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | SA388005444701 |
| Policy instance | 1 |
| Insurance contract or identification number | SA388005444701 | | Number of Individuals Covered | 2333 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $840,483 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | PD388005444701 |
| Policy instance | 3 |
| Insurance contract or identification number | PD388005444701 | | Number of Individuals Covered | 2097 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $21 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 21 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF388005444701 |
| Policy instance | 4 |
| Insurance contract or identification number | GF388005444701 | | Number of Individuals Covered | 2173 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $3,103 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $236,696 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3103 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 9770710 |
| Policy instance | 5 |
| Insurance contract or identification number | 9770710 | | Number of Individuals Covered | 4124 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $160,418 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0307343 |
| Policy instance | 6 |
| Insurance contract or identification number | 0307343 | | Number of Individuals Covered | 1816 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | 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 0009138099 |
| Policy instance | 7 |
| Insurance contract or identification number | GTP 0009138099 | | Number of Individuals Covered | 2292 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-10-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $10,736 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 716251 |
| Policy instance | 2 |
| Insurance contract or identification number | 716251 | | Number of Individuals Covered | 4810 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,698,099 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | SA388005444701 |
| Policy instance | 1 |
| Insurance contract or identification number | SA388005444701 | | Number of Individuals Covered | 2181 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $8,215 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $630,487 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 8215 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | SA388005444701 |
| Policy instance | 1 |
| Insurance contract or identification number | SA388005444701 | | Number of Individuals Covered | 2131 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $586,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 716251 |
| Policy instance | 2 |
| Insurance contract or identification number | 716251 | | Number of Individuals Covered | 1868 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $2,033,992 | | 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 0009138099 |
| Policy instance | 7 |
| Insurance contract or identification number | GTP 0009138099 | | Number of Individuals Covered | 2305 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-10-01 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $10,736 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0307343 |
| Policy instance | 6 |
| Insurance contract or identification number | 0307343 | | Number of Individuals Covered | 1789 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 9770710 |
| Policy instance | 5 |
| Insurance contract or identification number | 9770710 | | Number of Individuals Covered | 4048 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $146,890 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF388005444701 |
| Policy instance | 4 |
| Insurance contract or identification number | GF388005444701 | | Number of Individuals Covered | 2021 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $230,315 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | PD388005444701 |
| Policy instance | 3 |
| Insurance contract or identification number | PD388005444701 | | Number of Individuals Covered | 2021 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 9770710 |
| Policy instance | 5 |
| Insurance contract or identification number | 9770710 | | Number of Individuals Covered | 3870 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $174,189 | | 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 0009138099 |
| Policy instance | 8 |
| Insurance contract or identification number | GTP 0009138099 | | Number of Individuals Covered | 2056 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,734 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0307343 |
| Policy instance | 7 |
| Insurance contract or identification number | 0307343 | | Number of Individuals Covered | 1745 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | 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 | 011886 |
| Policy instance | 3 |
| Insurance contract or identification number | 011886 | | Number of Individuals Covered | 1912 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 716251 |
| Policy instance | 2 |
| Insurance contract or identification number | 716251 | | Number of Individuals Covered | 1844 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $1,436,510 | | 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 | 11886 |
| Policy instance | 1 |
| Insurance contract or identification number | 11886 | | Number of Individuals Covered | 2056 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $624,367 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 05253A |
| Policy instance | 6 |
| Insurance contract or identification number | 05253A | | Number of Individuals Covered | 1 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | MEDICAL BENEFITS ABROAD COVERAGE | | Welfare Benefit Premiums Paid to Carrier | USD $1,613 | | 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 | 011886 |
| Policy instance | 4 |
| Insurance contract or identification number | 011886 | | Number of Individuals Covered | 1912 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $195,915 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 05253A |
| Policy instance | 7 |
| Insurance contract or identification number | 05253A | | Number of Individuals Covered | 1928 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | MEDICAL BENEFITS ABROAD COVERAGE | | Welfare Benefit Premiums Paid to Carrier | USD $9,680 | | 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 0009138099 |
| Policy instance | 9 |
| Insurance contract or identification number | GTP 0009138099 | | Number of Individuals Covered | 1928 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,734 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0307343 |
| Policy instance | 8 |
| Insurance contract or identification number | 0307343 | | Number of Individuals Covered | 1793 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 9770710 |
| Policy instance | 6 |
| Insurance contract or identification number | 9770710 | | Number of Individuals Covered | 3637 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $156,715 | | 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 | 11886 |
| Policy instance | 1 |
| Insurance contract or identification number | 11886 | | Number of Individuals Covered | 2104 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $612,965 | | 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 | 011886 |
| Policy instance | 5 |
| Insurance contract or identification number | 011886 | | Number of Individuals Covered | 1993 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $182,129 | | 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 | 011886 |
| Policy instance | 4 |
| Insurance contract or identification number | 011886 | | Number of Individuals Covered | 1993 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL961398 |
| Policy instance | 3 |
| Insurance contract or identification number | ABL961398 | | Number of Individuals Covered | 1928 | | Insurance policy start date | 2011-08-08 | | Insurance policy end date | 2012-10-07 | | Total amount of commissions paid to insurance broker | USD $39 | | 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 | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,293 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 716251 & 716252 |
| Policy instance | 2 |
| Insurance contract or identification number | 716251 & 716252 | | Number of Individuals Covered | 1845 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $1,363,505 | | 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 | 011886 |
| Policy instance | 5 |
| Insurance contract or identification number | 011886 | | Number of Individuals Covered | 1750 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $145,566 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0307343 |
| Policy instance | 8 |
| Insurance contract or identification number | 0307343 | | Number of Individuals Covered | 1766 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 05253A |
| Policy instance | 7 |
| Insurance contract or identification number | 05253A | | Number of Individuals Covered | 1 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | MEDICAL BENEFITS ABROAD COVERAGE | | Welfare Benefit Premiums Paid to Carrier | USD $9,680 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 9770710 |
| Policy instance | 6 |
| Insurance contract or identification number | 9770710 | | Number of Individuals Covered | 3122 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $133,075 | | 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 | 011886 |
| Policy instance | 4 |
| Insurance contract or identification number | 011886 | | Number of Individuals Covered | 1750 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL961398 |
| Policy instance | 3 |
| Insurance contract or identification number | ABL961398 | | Number of Individuals Covered | 1855 | | Insurance policy start date | 2010-08-08 | | Insurance policy end date | 2011-08-08 | | Total amount of commissions paid to insurance broker | USD $65 | | 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 | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 716251 & 716252 |
| Policy instance | 2 |
| Insurance contract or identification number | 716251 & 716252 | | Number of Individuals Covered | 1678 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $1,186,549 | | 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 | 11886 |
| Policy instance | 1 |
| Insurance contract or identification number | 11886 | | Number of Individuals Covered | 1855 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $561,788 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 716251 & 716252 |
| Policy instance | 2 |
| Insurance contract or identification number | 716251 & 716252 | | Number of Individuals Covered | 1559 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $829,955 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0307343 |
| Policy instance | 3 |
| Insurance contract or identification number | 0307343 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL961398 |
| Policy instance | 4 |
| Insurance contract or identification number | ABL961398 | | Number of Individuals Covered | 1705 | | Insurance policy start date | 2009-08-08 | | Insurance policy end date | 2010-08-08 | | Total amount of commissions paid to insurance broker | USD $16 | | 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 | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,511 | | 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 | 011886 |
| Policy instance | 5 |
| Insurance contract or identification number | 011886 | | Number of Individuals Covered | 1618 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 9770710 |
| Policy instance | 7 |
| Insurance contract or identification number | 9770710 | | Number of Individuals Covered | 2097 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $89,022 | | 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 | 011886 |
| Policy instance | 6 |
| Insurance contract or identification number | 011886 | | Number of Individuals Covered | 1618 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $109,092 | | 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 | 11886 |
| Policy instance | 1 |
| Insurance contract or identification number | 11886 | | Number of Individuals Covered | 1692 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $530,816 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
