BIG Y FOODS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan BIG Y FOODS, INC. HEALTH AND DENTAL PLAN
| Measure | Date | Value |
|---|
| 2012 : BIG Y FOODS, INC. HEALTH AND DENTAL PLAN 2012 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2012-06-30 | $0 |
| Total transfer of assets to this plan | 2012-06-30 | $0 |
| Total transfer of assets from this plan | 2012-06-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-06-30 | $586,078 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-06-30 | $714,205 |
| Total income from all sources (including contributions) | 2012-06-30 | $26,629,133 |
| Total loss/gain on sale of assets | 2012-06-30 | $0 |
| Total of all expenses incurred | 2012-06-30 | $26,391,133 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-06-30 | $24,672,248 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-06-30 | $26,748,975 |
| Value of total assets at end of year | 2012-06-30 | $2,686,078 |
| Value of total assets at beginning of year | 2012-06-30 | $2,576,205 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-06-30 | $1,718,885 |
| Total interest from all sources | 2012-06-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2012-06-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-06-30 | Yes |
| Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan | 2012-06-30 | $0 |
| Administrative expenses professional fees incurred | 2012-06-30 | $7,810 |
| Was this plan covered by a fidelity bond | 2012-06-30 | Yes |
| Value of fidelity bond cover | 2012-06-30 | $2,500,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2012-06-30 | No |
| Contributions received from participants | 2012-06-30 | $4,895,495 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2012-06-30 | $172,400 |
| Liabilities. Value of operating payables at end of year | 2012-06-30 | $24,384 |
| Liabilities. Value of operating payables at beginning of year | 2012-06-30 | $23,758 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-06-30 | No |
| Value of net income/loss | 2012-06-30 | $238,000 |
| Value of net assets at end of year (total assets less liabilities) | 2012-06-30 | $2,100,000 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-06-30 | $1,862,000 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-06-30 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2012-06-30 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2012-06-30 | $1,655,002 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2012-06-30 | $131,895 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2012-06-30 | $131,895 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-06-30 | $512,478 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2012-06-30 | $-119,842 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2012-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-06-30 | No |
| Contributions received in cash from employer | 2012-06-30 | $21,853,480 |
| Employer contributions (assets) at end of year | 2012-06-30 | $2,686,078 |
| Employer contributions (assets) at beginning of year | 2012-06-30 | $616,908 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-06-30 | $24,159,770 |
| Contract administrator fees | 2012-06-30 | $1,711,075 |
| Liabilities. Value of benefit claims payable at end of year | 2012-06-30 | $561,694 |
| Liabilities. Value of benefit claims payable at beginning of year | 2012-06-30 | $690,447 |
| Did the plan have assets held for investment | 2012-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-06-30 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2012-06-30 | Disclaimer |
| Accountancy firm name | 2012-06-30 | MEYERS BROTHERS KALICKA, P.C. |
| Accountancy firm EIN | 2012-06-30 | 042713795 |
| 2011 : BIG Y FOODS, INC. HEALTH AND DENTAL PLAN 2011 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2011-06-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-06-30 | $714,205 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-06-30 | $190,949 |
| Total income from all sources (including contributions) | 2011-06-30 | $25,209,777 |
| Total loss/gain on sale of assets | 2011-06-30 | $0 |
| Total of all expenses incurred | 2011-06-30 | $25,219,777 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-06-30 | $22,855,869 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-06-30 | $24,990,562 |
| Value of total assets at end of year | 2011-06-30 | $2,576,205 |
| Value of total assets at beginning of year | 2011-06-30 | $2,062,949 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-06-30 | $2,363,908 |
| Total interest from all sources | 2011-06-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2011-06-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-06-30 | No |
| Administrative expenses professional fees incurred | 2011-06-30 | $122,564 |
| Was this plan covered by a fidelity bond | 2011-06-30 | Yes |
| Value of fidelity bond cover | 2011-06-30 | $2,500,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2011-06-30 | No |
| Contributions received from participants | 2011-06-30 | $5,463,848 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2011-06-30 | $172,400 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2011-06-30 | $172,400 |
| Liabilities. Value of operating payables at end of year | 2011-06-30 | $23,758 |
| Liabilities. Value of operating payables at beginning of year | 2011-06-30 | $21,218 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-06-30 | No |
| Value of net income/loss | 2011-06-30 | $-10,000 |
| Value of net assets at end of year (total assets less liabilities) | 2011-06-30 | $1,862,000 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-06-30 | $1,872,000 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-06-30 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2011-06-30 | $1,655,002 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2011-06-30 | $685,835 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2011-06-30 | $131,895 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2011-06-30 | $2,273 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2011-06-30 | $2,273 |
| Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year | 2011-06-30 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-06-30 | $276,992 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2011-06-30 | $219,215 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-06-30 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2011-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-06-30 | No |
| Contributions received in cash from employer | 2011-06-30 | $19,526,714 |
| Employer contributions (assets) at end of year | 2011-06-30 | $616,908 |
| Employer contributions (assets) at beginning of year | 2011-06-30 | $1,202,441 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-06-30 | $22,578,877 |
| Contract administrator fees | 2011-06-30 | $2,241,344 |
| Liabilities. Value of benefit claims payable at end of year | 2011-06-30 | $690,447 |
| Liabilities. Value of benefit claims payable at beginning of year | 2011-06-30 | $169,731 |
| Did the plan have assets held for investment | 2011-06-30 | 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 | 2011-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-06-30 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2011-06-30 | Disclaimer |
| Accountancy firm name | 2011-06-30 | MEYERS BROTHERS KALICKA, P.C. |
| Accountancy firm EIN | 2011-06-30 | 042713795 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR206681 |
| Policy instance | 5 |
| Insurance contract or identification number | VAR206681 | | Number of Individuals Covered | 1590 | | 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 $144 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $30,278 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD126485 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD126485 | | Number of Individuals Covered | 1003 | | 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 $1,429 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $272,365 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL154524 |
| Policy instance | 3 |
| Insurance contract or identification number | GL154524 | | Number of Individuals Covered | 1505 | | 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 $1,314 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $280,018 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL154523 |
| Policy instance | 2 |
| Insurance contract or identification number | GL154523 | | Number of Individuals Covered | 6125 | | 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 $1,271 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $274,346 | | 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 | 3306864 |
| Policy instance | 1 |
| Insurance contract or identification number | 3306864 | | Number of Individuals Covered | 281 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,561 | | 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 | 3306864 |
| Policy instance | 1 |
| Insurance contract or identification number | 3306864 | | Number of Individuals Covered | 309 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $61,126 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154523 |
| Policy instance | 2 |
| Insurance contract or identification number | GL 154523 | | Number of Individuals Covered | 6251 | | 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 $1,348 | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $254,162 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154524 |
| Policy instance | 3 |
| Insurance contract or identification number | GL 154524 | | Number of Individuals Covered | 1464 | | 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 $1,280 | | 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 $262,806 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 126485 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD 126485 | | Number of Individuals Covered | 1071 | | 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 $1,413 | | 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 $285,787 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 206681 |
| Policy instance | 5 |
| Insurance contract or identification number | VAR 206681 | | Number of Individuals Covered | 1613 | | 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 $142 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $28,885 | | 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 | 3306864 |
| Policy instance | 1 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154523 |
| Policy instance | 2 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154524 |
| Policy instance | 3 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 126485 |
| Policy instance | 4 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 206681 |
| Policy instance | 5 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 206681 |
| Policy instance | 5 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 126485 |
| Policy instance | 4 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154524 |
| Policy instance | 3 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154523 |
| Policy instance | 2 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3306864 |
| Policy instance | 1 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 206681 |
| Policy instance | 5 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 126485 |
| Policy instance | 4 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154524 |
| Policy instance | 3 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154523 |
| Policy instance | 2 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3306864 |
| Policy instance | 1 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3306864 |
| Policy instance | 1 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154523 |
| Policy instance | 2 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154524 |
| Policy instance | 3 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 126485 |
| Policy instance | 4 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 206681 |
| Policy instance | 5 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3306864 |
| Policy instance | 1 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154523 |
| Policy instance | 2 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154524 |
| Policy instance | 3 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 126485 |
| Policy instance | 4 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 206681 |
| Policy instance | 5 |
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | SA385029096401 |
| Policy instance | 2 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK030409 |
| Policy instance | 1 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3306864 |
| Policy instance | 1 |
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 3306864 |
| Policy instance | 1 |
