NEW YORK STATE UNITED TEACHERS has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan NEW YORK STATE UNITED TEACHERS STAFF WELFARE PLAN
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0009 |
| Policy instance | 3 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 01442 |
| Policy instance | 2 |
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NMC ALL GROUPS |
| Policy instance | 9 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 4 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 5 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 6 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 7 |
| THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 ) |
| Policy contract number | D573181 |
| Policy instance | 8 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 01442 |
| Policy instance | 2 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 3 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 4 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 5 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 7 |
| THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 ) |
| Policy contract number | D573181 |
| Policy instance | 8 |
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NMC ALL GROUPS |
| Policy instance | 9 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0009 |
| Policy instance | 6 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 5 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 01442 |
| Policy instance | 2 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 3 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 4 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0009 |
| Policy instance | 6 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 7 |
| THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 ) |
| Policy contract number | D573181 |
| Policy instance | 8 |
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NCM ALL GROUPS |
| Policy instance | 9 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 3 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 01442 |
| Policy instance | 2 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 5 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 6 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0009 |
| Policy instance | 7 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 8 |
| WESCO INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 25011 ) |
| Policy contract number | 0401140,001,002 |
| Policy instance | 9 |
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NMC |
| Policy instance | 4 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 8 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0009 |
| Policy instance | 7 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 6 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 5 |
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NMC |
| Policy instance | 4 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 3 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 01442 |
| Policy instance | 2 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| WESCO INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 25011 ) |
| Policy contract number | 0401140,001,002 |
| Policy instance | 9 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 3 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 01442 |
| Policy instance | 2 |
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NMC |
| Policy instance | 4 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 5 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 6 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0009 |
| Policy instance | 7 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 8 |
| WESCO INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 25011 ) |
| Policy contract number | 0401140,001,002 |
| Policy instance | 9 |
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 22339 |
| Policy instance | 12 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 000099070661 |
| Policy instance | 13 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 11 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0009 |
| Policy instance | 10 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 9 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0001 |
| Policy instance | 8 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0002 |
| Policy instance | 7 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 6 |
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 00416912 |
| Policy instance | 5 |
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NMC |
| Policy instance | 4 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 3 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 01442 |
| Policy instance | 2 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0002 |
| Policy instance | 8 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0009 |
| Policy instance | 10 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 11 |
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 000099070661 |
| Policy instance | 12 |
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 13364G |
| Policy instance | 13 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00008024-0001 |
| Policy instance | 7 |
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 00416912 |
| Policy instance | 5 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 6 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0001 |
| Policy instance | 9 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 14 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 01442 |
| Policy instance | 2 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 3 |
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NMC |
| Policy instance | 4 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 1442 |
| Policy instance | 2 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 3 |
| Insurance contract or identification number | F014621 | | Number of Individuals Covered | 644 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $22,094 | | 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 | Yes | | 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 $147,288 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker name | NEW YORK STATE UNITED TEACHERS |
|
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NMC |
| Policy instance | 4 |
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 313717 |
| Policy instance | 5 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 6 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0002 |
| Policy instance | 8 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0001 |
| Policy instance | 9 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0009 |
| Policy instance | 11 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00008024-0001 |
| Policy instance | 7 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 10 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 12 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 10 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 12 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 11 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0001 |
| Policy instance | 9 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0002 |
| Policy instance | 8 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 12413-001 |
| Policy instance | 7 |
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 313717 |
| Policy instance | 5 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 6 |
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NMC |
| Policy instance | 4 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 188668 0009 |
| Policy instance | 3 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 1442 |
| Policy instance | 2 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 10 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 1442 |
| Policy instance | 2 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 188668 0009 |
| Policy instance | 3 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 12413-001 |
| Policy instance | 7 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0001 |
| Policy instance | 9 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 6 |
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 313717 |
| Policy instance | 5 |
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 ) |
| Policy contract number | 13364H |
| Policy instance | 11 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 12 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 13 |
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NMC |
| Policy instance | 4 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0002 |
| Policy instance | 8 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 188668 0009 |
| Policy instance | 3 |
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 313717 |
| Policy instance | 5 |
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 1442 |
| Policy instance | 2 |
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10006051 |
| Policy instance | 1 |
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | NMC |
| Policy instance | 4 |
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 993419 |
| Policy instance | 6 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 12413-001 |
| Policy instance | 7 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0002 |
| Policy instance | 8 |
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 211932-0001 |
| Policy instance | 9 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118668 0008 |
| Policy instance | 10 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 118669 0009 |
| Policy instance | 12 |
| CVS PHARMACY, INC. (National Association of Insurance Commissioners NAIC id number: 44611 ) |
| Policy contract number | 2005552 |
| Policy instance | 13 |
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 ) |
| Policy contract number | 13364H |
| Policy instance | 11 |