FIESTA RESTAURANT GROUP, INC. has sponsored the creation of one or more 401k plans.
Additional information about FIESTA RESTAURANT GROUP, INC.
Submission information for form 5500 for 401k plan FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN
| 2023: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | Yes |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | Yes |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: FIESTA RESTAURANT GROUP, INC. HEALTH & WELFARE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-05-07 | Type of plan entity | Single employer plan |
| 2012-05-07 | First time form 5500 has been submitted | Yes |
| 2012-05-07 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2012-05-07 | Plan funding arrangement – Insurance | Yes |
| 2012-05-07 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-05-07 | Plan benefit arrangement – Insurance | Yes |
| 2012-05-07 | Plan benefit arrangement – General assets of the sponsor | Yes |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB142046 |
| Policy instance | 1 |
| Insurance contract or identification number | ETB142046 | | Number of Individuals Covered | 500 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $480 | | Total amount of fees paid to insurance company | USD $64 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,200 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0002 |
| Policy instance | 5 |
| Insurance contract or identification number | FSRG0002 | | Number of Individuals Covered | 500 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $8,413 | | 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 | FLX0968529 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX0968529 | | Number of Individuals Covered | 393 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $264,721 | | 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 | G1921 |
| Policy instance | 3 |
| Insurance contract or identification number | G1921 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $10,394 | | Total amount of fees paid to insurance company | USD $123 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $140,475 | | 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 | 922040 |
| Policy instance | 2 |
| Insurance contract or identification number | 922040 | | Number of Individuals Covered | 423 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $22,077 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $239,802 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB142046 |
| Policy instance | 1 |
| Insurance contract or identification number | ETB142046 | | Number of Individuals Covered | 500 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 922040 |
| Policy instance | 2 |
| Insurance contract or identification number | 922040 | | Number of Individuals Covered | 449 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $88,587 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $236,992 | | 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 | G1921 |
| Policy instance | 3 |
| Insurance contract or identification number | G1921 | | Number of Individuals Covered | 516 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $16,353 | | Total amount of fees paid to insurance company | USD $128 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $147,733 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0002 |
| Policy instance | 4 |
| Insurance contract or identification number | FSRG0002 | | Number of Individuals Covered | 500 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $15,998 | | 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 | FLX968529 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX968529 | | Number of Individuals Covered | 500 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $7,828 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $228,943 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 922040 |
| Policy instance | 2 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0003 |
| Policy instance | 3 |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | G1921 |
| Policy instance | 4 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0001 |
| Policy instance | 5 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX968529 |
| Policy instance | 6 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB142046 |
| Policy instance | 1 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0001 |
| Policy instance | 3 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3337366 |
| Policy instance | 2 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB142046 |
| Policy instance | 1 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX968529 |
| Policy instance | 4 |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | G1921 |
| Policy instance | 3 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0001 |
| Policy instance | 4 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX968529 |
| Policy instance | 5 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB142046 |
| Policy instance | 1 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3337366 |
| Policy instance | 2 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0001 |
| Policy instance | 3 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX968529 |
| Policy instance | 4 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0002 |
| Policy instance | 1 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB142046 |
| Policy instance | 2 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3337366 |
| Policy instance | 3 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0001 |
| Policy instance | 5 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0003 |
| Policy instance | 4 |
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | SA388003591001 |
| Policy instance | 6 |
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | SA388003591001 |
| Policy instance | 7 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0-001 |
| Policy instance | 6 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0-003 |
| Policy instance | 5 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3337366 |
| Policy instance | 4 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB142046 |
| Policy instance | 3 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30028666 |
| Policy instance | 2 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0002 |
| Policy instance | 1 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB142046 |
| Policy instance | 1 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3337366 |
| Policy instance | 2 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0-001 |
| Policy instance | 3 |
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | SA388003591001 |
| Policy instance | 4 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30028666 |
| Policy instance | 5 |
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | SA388003591001 |
| Policy instance | 1 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0-1,2,3 |
| Policy instance | 2 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30028666 |
| Policy instance | 3 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB142046 |
| Policy instance | 4 |
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF388003591001 |
| Policy instance | 6 |
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GD388003591001 |
| Policy instance | 5 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3337366 |
| Policy instance | 7 |
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF3/GD3 8800359 |
| Policy instance | 2 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00033697 |
| Policy instance | 1 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0-002 |
| Policy instance | 3 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FSRG0-003 |
| Policy instance | 4 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 ) |
| Policy contract number | 30028666 |
| Policy instance | 5 |
| CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLY980007 |
| Policy instance | 6 |
| CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | ABY980005 |
| Policy instance | 7 |
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | 80185,70185 |
| Policy instance | 8 |
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | TDP03 TDP06 |
| Policy instance | 9 |
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NDP01 |
| Policy instance | 10 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB106469 |
| Policy instance | 11 |
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GF3-880-035910- |
| Policy instance | 6 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00033697 |
| Policy instance | 5 |
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GD3-880-035910- |
| Policy instance | 4 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 514156 |
| Policy instance | 3 |
| CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | YOK980007 |
| Policy instance | 2 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 ) |
| Policy contract number | 30028666 |
| Policy instance | 7 |
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | 80185/70185 |
| Policy instance | 8 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | 190047 |
| Policy instance | 9 |
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | TDP03/TDP06 |
| Policy instance | 10 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB-106469 |
| Policy instance | 12 |
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NDP01 |
| Policy instance | 11 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | 190296 |
| Policy instance | 13 |
| CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLY980007 |
| Policy instance | 1 |
