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SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST 401k Plan overview

Plan NameSRC OF LEXINGTON INC HEALTH AND WELFARE TRUST
Plan identification number 502

SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST Benefits

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

401k Sponsoring company profile

SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST has sponsored the creation of one or more 401k plans.

Company Name:SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST
Employer identification number (EIN):856130701
NAIC Classification:333200

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022024-01-01GREG HAMPTON
5022023-01-01
5022023-01-01GREG HAMPTON
5022022-01-01
5022022-01-01NATASHA HUMPHREYS
5022021-01-01
5022021-01-01
5022021-01-01NATASHA HUMPHREYS
5022020-01-01

Financial Data on SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST

Measure Date Value
2023 : SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST 2023 401k financial data
Total income from all sources (including contributions)2023-12-31$2,042,894
Total of all expenses incurred2023-12-31$2,050,715
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2023-12-31$1,908,564
Total contributions o plan (from employers,participants, others, non cash contrinutions)2023-12-31$2,042,894
Value of total assets at end of year2023-12-31$65,430
Value of total assets at beginning of year2023-12-31$73,251
Total of administrative expenses incurred including professional, contract, advisory and management fees2023-12-31$142,151
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2023-12-31No
Was this plan covered by a fidelity bond2023-12-31Yes
Value of fidelity bond cover2023-12-31$2,000,000
If this is an individual account plan, was there a blackout period2023-12-31No
Were there any nonexempt tranactions with any party-in-interest2023-12-31No
Contributions received from participants2023-12-31$348,297
Total non interest bearing cash at end of year2023-12-31$65,430
Total non interest bearing cash at beginning of year2023-12-31$73,251
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2023-12-31No
Value of net income/loss2023-12-31$-7,821
Value of net assets at end of year (total assets less liabilities)2023-12-31$65,430
Value of net assets at beginning of year (total assets less liabilities)2023-12-31$73,251
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2023-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2023-12-31No
Were any leases to which the plan was party in default or uncollectible2023-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2023-12-31$529,916
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2023-12-31No
Was there a failure to transmit to the plan any participant contributions2023-12-31No
Has the plan failed to provide any benefit when due under the plan2023-12-31No
Contributions received in cash from employer2023-12-31$1,694,597
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2023-12-31$1,378,648
Contract administrator fees2023-12-31$139,151
Did the plan have assets held for investment2023-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2023-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2023-12-31No
Opinion of an independent qualified public accountant for this plan2023-12-31Unqualified
Accountancy firm name2023-12-31FRANK N HESTAND CPA PSC
Accountancy firm EIN2023-12-31611336870
Total income from all sources (including contributions)2023-01-01$2,042,894
Total of all expenses incurred2023-01-01$2,050,715
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2023-01-01$1,908,564
Total contributions o plan (from employers,participants, others, non cash contrinutions)2023-01-01$2,042,894
Value of total assets at end of year2023-01-01$65,430
Value of total assets at beginning of year2023-01-01$73,251
Total of administrative expenses incurred including professional, contract, advisory and management fees2023-01-01$142,151
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2023-01-01No
Was this plan covered by a fidelity bond2023-01-01Yes
Value of fidelity bond cover2023-01-01$2,000,000
If this is an individual account plan, was there a blackout period2023-01-01No
Were there any nonexempt tranactions with any party-in-interest2023-01-01No
Contributions received from participants2023-01-01$348,297
Total non interest bearing cash at end of year2023-01-01$65,430
Total non interest bearing cash at beginning of year2023-01-01$73,251
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2023-01-01No
Value of net income/loss2023-01-01$-7,821
Value of net assets at end of year (total assets less liabilities)2023-01-01$65,430
Value of net assets at beginning of year (total assets less liabilities)2023-01-01$73,251
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2023-01-01No
Were any loans by the plan or fixed income obligations due to the plan in default2023-01-01No
Were any leases to which the plan was party in default or uncollectible2023-01-01No
Expenses. Payments to insurance carriers foe the provision of benefits2023-01-01$529,916
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2023-01-01No
Was there a failure to transmit to the plan any participant contributions2023-01-01No
Has the plan failed to provide any benefit when due under the plan2023-01-01No
Contributions received in cash from employer2023-01-01$1,694,597
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2023-01-01$1,378,648
Contract administrator fees2023-01-01$139,151
Did the plan have assets held for investment2023-01-01No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2023-01-01No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2023-01-01No
Opinion of an independent qualified public accountant for this plan2023-01-011
Accountancy firm name2023-01-01FRANK N HESTAND CPA PSC
Accountancy firm EIN2023-01-01611336870
2022 : SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST 2022 401k financial data
Total income from all sources (including contributions)2022-12-31$2,018,623
Total of all expenses incurred2022-12-31$1,934,748
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2022-12-31$1,799,191
Total contributions o plan (from employers,participants, others, non cash contrinutions)2022-12-31$2,018,623
Value of total assets at end of year2022-12-31$73,251
Value of total assets at beginning of year2022-12-31$-10,624
Total of administrative expenses incurred including professional, contract, advisory and management fees2022-12-31$135,557
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2022-12-31No
Was this plan covered by a fidelity bond2022-12-31Yes
Value of fidelity bond cover2022-12-31$2,000,000
If this is an individual account plan, was there a blackout period2022-12-31No
Were there any nonexempt tranactions with any party-in-interest2022-12-31No
Contributions received from participants2022-12-31$310,301
Administrative expenses (other) incurred2022-12-31$3,000
Total non interest bearing cash at end of year2022-12-31$73,251
Total non interest bearing cash at beginning of year2022-12-31$-10,624
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Value of net income/loss2022-12-31$83,875
Value of net assets at end of year (total assets less liabilities)2022-12-31$73,251
Value of net assets at beginning of year (total assets less liabilities)2022-12-31$-10,624
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2022-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2022-12-31No
Were any leases to which the plan was party in default or uncollectible2022-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2022-12-31$408,314
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2022-12-31No
Was there a failure to transmit to the plan any participant contributions2022-12-31No
Has the plan failed to provide any benefit when due under the plan2022-12-31No
Contributions received in cash from employer2022-12-31$1,708,322
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2022-12-31$1,390,877
Contract administrator fees2022-12-31$132,557
Did the plan have assets held for investment2022-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2022-12-31No
Opinion of an independent qualified public accountant for this plan2022-12-31Unqualified
Accountancy firm name2022-12-31FRANK N HESTAND CPA PSC
Accountancy firm EIN2022-12-31611336870
Total income from all sources (including contributions)2022-01-01$2,018,623
Total of all expenses incurred2022-01-01$1,934,748
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2022-01-01$1,799,191
Total contributions o plan (from employers,participants, others, non cash contrinutions)2022-01-01$2,018,623
Value of total assets at end of year2022-01-01$73,251
Value of total assets at beginning of year2022-01-01$-10,624
Total of administrative expenses incurred including professional, contract, advisory and management fees2022-01-01$135,557
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2022-01-01No
Was this plan covered by a fidelity bond2022-01-01Yes
Value of fidelity bond cover2022-01-01$2,000,000
If this is an individual account plan, was there a blackout period2022-01-01No
Were there any nonexempt tranactions with any party-in-interest2022-01-01No
Contributions received from participants2022-01-01$310,301
Administrative expenses (other) incurred2022-01-01$3,000
Total non interest bearing cash at end of year2022-01-01$73,251
Total non interest bearing cash at beginning of year2022-01-01$-10,624
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2022-01-01No
Value of net income/loss2022-01-01$83,875
Value of net assets at end of year (total assets less liabilities)2022-01-01$73,251
Value of net assets at beginning of year (total assets less liabilities)2022-01-01$-10,624
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2022-01-01No
Were any loans by the plan or fixed income obligations due to the plan in default2022-01-01No
Were any leases to which the plan was party in default or uncollectible2022-01-01No
Expenses. Payments to insurance carriers foe the provision of benefits2022-01-01$408,314
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2022-01-01No
Was there a failure to transmit to the plan any participant contributions2022-01-01No
Has the plan failed to provide any benefit when due under the plan2022-01-01No
Contributions received in cash from employer2022-01-01$1,708,322
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2022-01-01$1,390,877
Contract administrator fees2022-01-01$132,557
Did the plan have assets held for investment2022-01-01No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2022-01-01No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2022-01-01No
Opinion of an independent qualified public accountant for this plan2022-01-011
Accountancy firm name2022-01-01FRANK N HESTAND CPA PSC
Accountancy firm EIN2022-01-01611336870
2021 : SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST 2021 401k financial data
Total income from all sources (including contributions)2021-12-31$1,455,268
Total of all expenses incurred2021-12-31$1,512,256
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2021-12-31$1,388,997
Total contributions o plan (from employers,participants, others, non cash contrinutions)2021-12-31$1,455,268
Value of total assets at end of year2021-12-31$-10,624
Value of total assets at beginning of year2021-12-31$46,364
Total of administrative expenses incurred including professional, contract, advisory and management fees2021-12-31$123,259
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-12-31No
Was this plan covered by a fidelity bond2021-12-31Yes
Value of fidelity bond cover2021-12-31$2,000,000
If this is an individual account plan, was there a blackout period2021-12-31No
Were there any nonexempt tranactions with any party-in-interest2021-12-31No
Contributions received from participants2021-12-31$292,010
Administrative expenses (other) incurred2021-12-31$3,250
Total non interest bearing cash at end of year2021-12-31$-10,624
Total non interest bearing cash at beginning of year2021-12-31$46,364
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Value of net income/loss2021-12-31$-56,988
Value of net assets at end of year (total assets less liabilities)2021-12-31$-10,624
Value of net assets at beginning of year (total assets less liabilities)2021-12-31$46,364
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2021-12-31No
Were any leases to which the plan was party in default or uncollectible2021-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2021-12-31$416,300
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-12-31No
Was there a failure to transmit to the plan any participant contributions2021-12-31No
Has the plan failed to provide any benefit when due under the plan2021-12-31No
Contributions received in cash from employer2021-12-31$1,163,258
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2021-12-31$972,697
Contract administrator fees2021-12-31$120,009
Did the plan have assets held for investment2021-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-12-31No
Opinion of an independent qualified public accountant for this plan2021-12-31Unqualified
Accountancy firm name2021-12-31FRANK N HESTAND CPA PSC
Accountancy firm EIN2021-12-31611336870
2020 : SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST 2020 401k financial data
Total income from all sources (including contributions)2020-12-31$1,695,933
Total of all expenses incurred2020-12-31$1,649,569
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2020-12-31$1,506,599
Total contributions o plan (from employers,participants, others, non cash contrinutions)2020-12-31$1,695,933
Value of total assets at end of year2020-12-31$46,364
Total of administrative expenses incurred including professional, contract, advisory and management fees2020-12-31$142,970
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-12-31No
Was this plan covered by a fidelity bond2020-12-31Yes
Value of fidelity bond cover2020-12-31$2,000,000
If this is an individual account plan, was there a blackout period2020-12-31No
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Contributions received from participants2020-12-31$314,088
Administrative expenses (other) incurred2020-12-31$3,000
Total non interest bearing cash at end of year2020-12-31$46,364
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Value of net income/loss2020-12-31$46,364
Value of net assets at end of year (total assets less liabilities)2020-12-31$46,364
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2020-12-31No
Were any leases to which the plan was party in default or uncollectible2020-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2020-12-31$466,534
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-12-31No
Was there a failure to transmit to the plan any participant contributions2020-12-31No
Has the plan failed to provide any benefit when due under the plan2020-12-31No
Contributions received in cash from employer2020-12-31$1,381,845
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2020-12-31$1,040,065
Contract administrator fees2020-12-31$139,970
Did the plan have assets held for investment2020-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-12-31No
Opinion of an independent qualified public accountant for this plan2020-12-31Unqualified
Accountancy firm name2020-12-31FRANK N HESTAND CPA PSC
Accountancy firm EIN2020-12-31611336870

Form 5500 Responses for SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST

2023: SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST 2023 form 5500 responses
2023-01-01Type of plan entitySingle employer plan
2023-01-01Plan funding arrangement – TrustYes
2023-01-01Plan benefit arrangement – InsuranceYes
2023-01-01Plan benefit arrangement - TrustYes
2023-01-01Plan benefit arrangement – General assets of the sponsorYes
2022: SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – TrustYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement - TrustYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedYes
2021-01-01Plan funding arrangement – TrustYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement - TrustYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: SRC OF LEXINGTON INC HEALTH AND WELFARE TRUST 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01First time form 5500 has been submittedYes
2020-01-01Plan funding arrangement – TrustYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement - TrustYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number170761
Policy instance 6
Insurance contract or identification number170761
Number of Individuals Covered128
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $6,552
Total amount of fees paid to insurance companyUSD $2,560
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number417004414224
Policy instance 1
Insurance contract or identification number417004414224
Number of Individuals Covered157
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $2
Total amount of fees paid to insurance companyUSD $14,546
Welfare Benefit Premiums Paid to CarrierUSD $272,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )
Policy contract number0691590
Policy instance 2
Insurance contract or identification number0691590
Number of Individuals Covered347
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $8,242
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )
Policy contract numberW26740
Policy instance 3
Insurance contract or identification numberW26740
Number of Individuals Covered148
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $1,777
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $29,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number170761
Policy instance 4
Insurance contract or identification number170761
Number of Individuals Covered167
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $11,764
Total amount of fees paid to insurance companyUSD $4,811
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number170761
Policy instance 5
Insurance contract or identification number170761
Number of Individuals Covered94
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $3,227
Total amount of fees paid to insurance companyUSD $1,245
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )
Policy contract numberW26740
Policy instance 5
DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )
Policy contract number0691590
Policy instance 4
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number000FK413
Policy instance 3
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract number417003414224
Policy instance 2
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract number417002414224
Policy instance 1
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract number417002414224
Policy instance 1
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract number417003414224
Policy instance 2
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number000FK413
Policy instance 3
DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )
Policy contract number0691590
Policy instance 4
ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )
Policy contract numberW26740
Policy instance 5
DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )
Policy contract number0691590
Policy instance 4
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number000FK413
Policy instance 3
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract number417003414224
Policy instance 2
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract number417002414224
Policy instance 1

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