401k Plan data: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED plan

HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 401k Plan overview

Plan Name	HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED
Plan identification number	502

HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental

401k Sponsoring company profile

COMMUNITY SERVICES FOR EVERY1 INC has sponsored the creation of one or more 401k plans.

Company Name: COMMUNITY SERVICES FOR EVERY1 INC

Employer identification number (EIN): 161317369

NAIC Classification: 624100
NAIC Description: Individual and Family Services

Additional information about COMMUNITY SERVICES FOR EVERY1 INC

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1987-02-10

Company Identification Number: 1143562

Legal Registered Office Address: ATTN: MINDY CERVONI
180 OAK STREET
BUFFALO
United States of America (USA)
14203

More information about COMMUNITY SERVICES FOR EVERY1 INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2018-03-01 MINDY CERVONI
502 2017-03-01 MINDY CERVONI
502 2016-03-01 MINDY CERVONI
502 2015-03-01 MINDY CERVONI
502 2014-03-01 MINDY CERVONI
502 2013-03-01 MARK R. FOLEY
502 2012-03-01 MARK R. FOLEY
502 2011-03-01 MARK R. FOLEY
502 2009-03-01 MARK R FOLEY

Plan id#	Filing Submission Date	Name of Administrator
502	2018-03-01	MINDY CERVONI
502	2017-03-01	MINDY CERVONI
502	2016-03-01	MINDY CERVONI
502	2015-03-01	MINDY CERVONI
502	2014-03-01	MINDY CERVONI
502	2013-03-01	MARK R. FOLEY
502	2012-03-01	MARK R. FOLEY
502	2011-03-01	MARK R. FOLEY
502	2009-03-01	MARK R FOLEY

Plan Statistics for HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED

401k plan membership statisitcs for HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED

Measure Date Value
2018: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2018 401k membership
Total participants, beginning-of-year 2018-03-01 220
Total number of active participants reported on line 7a of the Form 5500 2018-03-01 0
Number of retired or separated participants receiving benefits 2018-03-01 0
Number of other retired or separated participants entitled to future benefits 2018-03-01 0
Total of all active and inactive participants 2018-03-01 0
2017: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2017 401k membership
Total participants, beginning-of-year 2017-03-01 239
Total number of active participants reported on line 7a of the Form 5500 2017-03-01 220
Number of retired or separated participants receiving benefits 2017-03-01 0
Number of other retired or separated participants entitled to future benefits 2017-03-01 0
Total of all active and inactive participants 2017-03-01 220
2016: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2016 401k membership
Total participants, beginning-of-year 2016-03-01 243
Total number of active participants reported on line 7a of the Form 5500 2016-03-01 239
Number of retired or separated participants receiving benefits 2016-03-01 0
Number of other retired or separated participants entitled to future benefits 2016-03-01 0
Total of all active and inactive participants 2016-03-01 239
2015: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2015 401k membership
Total participants, beginning-of-year 2015-03-01 269
Total number of active participants reported on line 7a of the Form 5500 2015-03-01 249
Number of retired or separated participants receiving benefits 2015-03-01 0
Number of other retired or separated participants entitled to future benefits 2015-03-01 0
Total of all active and inactive participants 2015-03-01 249
2014: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2014 401k membership
Total participants, beginning-of-year 2014-03-01 281
Total number of active participants reported on line 7a of the Form 5500 2014-03-01 245
Number of retired or separated participants receiving benefits 2014-03-01 6
Total of all active and inactive participants 2014-03-01 251
2013: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2013 401k membership
Total participants, beginning-of-year 2013-03-01 365
Total number of active participants reported on line 7a of the Form 5500 2013-03-01 332
Number of retired or separated participants receiving benefits 2013-03-01 2
Number of other retired or separated participants entitled to future benefits 2013-03-01 20
Total of all active and inactive participants 2013-03-01 354
2012: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2012 401k membership
Total participants, beginning-of-year 2012-03-01 451
Total number of active participants reported on line 7a of the Form 5500 2012-03-01 394
Total of all active and inactive participants 2012-03-01 394
2011: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2011 401k membership
Total participants, beginning-of-year 2011-03-01 462
Total number of active participants reported on line 7a of the Form 5500 2011-03-01 451
Total of all active and inactive participants 2011-03-01 451
2009: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2009 401k membership
Total participants, beginning-of-year 2009-03-01 489
Total number of active participants reported on line 7a of the Form 5500 2009-03-01 458
Total of all active and inactive participants 2009-03-01 458
Total participants 2009-03-01 458

Measure	Date	Value
2018: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2018 401k membership
Total participants, beginning-of-year	2018-03-01	220
Total number of active participants reported on line 7a of the Form 5500	2018-03-01	0
Number of retired or separated participants receiving benefits	2018-03-01	0
Number of other retired or separated participants entitled to future benefits	2018-03-01	0
Total of all active and inactive participants	2018-03-01	0
2017: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2017 401k membership
Total participants, beginning-of-year	2017-03-01	239
Total number of active participants reported on line 7a of the Form 5500	2017-03-01	220
Number of retired or separated participants receiving benefits	2017-03-01	0
Number of other retired or separated participants entitled to future benefits	2017-03-01	0
Total of all active and inactive participants	2017-03-01	220
2016: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2016 401k membership
Total participants, beginning-of-year	2016-03-01	243
Total number of active participants reported on line 7a of the Form 5500	2016-03-01	239
Number of retired or separated participants receiving benefits	2016-03-01	0
Number of other retired or separated participants entitled to future benefits	2016-03-01	0
Total of all active and inactive participants	2016-03-01	239
2015: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2015 401k membership
Total participants, beginning-of-year	2015-03-01	269
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	249
Number of retired or separated participants receiving benefits	2015-03-01	0
Number of other retired or separated participants entitled to future benefits	2015-03-01	0
Total of all active and inactive participants	2015-03-01	249
2014: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2014 401k membership
Total participants, beginning-of-year	2014-03-01	281
Total number of active participants reported on line 7a of the Form 5500	2014-03-01	245
Number of retired or separated participants receiving benefits	2014-03-01	6
Total of all active and inactive participants	2014-03-01	251
2013: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2013 401k membership
Total participants, beginning-of-year	2013-03-01	365
Total number of active participants reported on line 7a of the Form 5500	2013-03-01	332
Number of retired or separated participants receiving benefits	2013-03-01	2
Number of other retired or separated participants entitled to future benefits	2013-03-01	20
Total of all active and inactive participants	2013-03-01	354
2012: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2012 401k membership
Total participants, beginning-of-year	2012-03-01	451
Total number of active participants reported on line 7a of the Form 5500	2012-03-01	394
Total of all active and inactive participants	2012-03-01	394
2011: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2011 401k membership
Total participants, beginning-of-year	2011-03-01	462
Total number of active participants reported on line 7a of the Form 5500	2011-03-01	451
Total of all active and inactive participants	2011-03-01	451
2009: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2009 401k membership
Total participants, beginning-of-year	2009-03-01	489
Total number of active participants reported on line 7a of the Form 5500	2009-03-01	458
Total of all active and inactive participants	2009-03-01	458
Total participants	2009-03-01	458

Form 5500 Responses for HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED

2018: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2018 form 5500 responses
2018-03-01	Type of plan entity	Single employer plan
2018-03-01	This submission is the final filing	Yes
2018-03-01	Plan funding arrangement – Insurance	Yes
2018-03-01	Plan benefit arrangement – Insurance	Yes
2017: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2017 form 5500 responses
2017-03-01	Type of plan entity	Single employer plan
2017-03-01	Plan funding arrangement – Insurance	Yes
2017-03-01	Plan benefit arrangement – Insurance	Yes
2016: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes
2015: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2014: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2014 form 5500 responses
2014-03-01	Type of plan entity	Single employer plan
2014-03-01	Plan funding arrangement – Insurance	Yes
2014-03-01	Plan benefit arrangement – Insurance	Yes
2013: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2013 form 5500 responses
2013-03-01	Type of plan entity	Single employer plan
2013-03-01	Plan funding arrangement – Insurance	Yes
2013-03-01	Plan benefit arrangement – Insurance	Yes
2012: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2012 form 5500 responses
2012-03-01	Type of plan entity	Single employer plan
2012-03-01	Plan funding arrangement – Insurance	Yes
2012-03-01	Plan benefit arrangement – Insurance	Yes
2011: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2011 form 5500 responses
2011-03-01	Type of plan entity	Single employer plan
2011-03-01	Plan funding arrangement – Insurance	Yes
2011-03-01	Plan benefit arrangement – Insurance	Yes
2009: HEALTH CARE PLAN FOR THE EMPLOYEES OF COMMUNITY SERVICES FOR THE DEVELOPMENTALLY DISABLED 2009 form 5500 responses
2009-03-01	Type of plan entity	Single employer plan
2009-03-01	Plan funding arrangement – Insurance	Yes
2009-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

21588-01

Policy instance

Insurance contract or identification number	21588-01
Number of Individuals Covered	73
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $12,096
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $573,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,096
Insurance broker name	THE BERT COMPANY

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 )

Policy contract number

21588-01

Policy instance

Insurance contract or identification number	21588-01
Number of Individuals Covered	271
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $34,427
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,591,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,427
Insurance broker name	THE BERT COMPANY

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00411754

Policy instance

Insurance contract or identification number	00411754
Number of Individuals Covered	220
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $3,547
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $103,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,547
Insurance broker name	THE BERT COMPANY

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 )

Policy contract number

21588

Policy instance

Insurance contract or identification number	21588
Number of Individuals Covered	398
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $41,919
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,040,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,824
Insurance broker name	THE BERT COMPANY

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00411754

Policy instance

Insurance contract or identification number	00411754
Number of Individuals Covered	249
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $5,119
Total amount of fees paid to insurance company	USD $775
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $100,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,398
Amount paid for insurance broker fees	775
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	THE BERT COMPANY

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

21588

Policy instance

Insurance contract or identification number	21588
Number of Individuals Covered	391
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,194,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00411754

Policy instance

Insurance contract or identification number	00411754
Number of Individuals Covered	236
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $103,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

31588H

Policy instance

Insurance contract or identification number	31588H
Number of Individuals Covered	107
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $609,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

31588F

Policy instance

Insurance contract or identification number	31588F
Number of Individuals Covered	33
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $32,412
Total amount of fees paid to insurance company	USD $10,945
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $196,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,412
Amount paid for insurance broker fees	10945
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	NORTHWEST INSURANCE SERVICES

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 )

Policy contract number

B6848Y

Policy instance

Insurance contract or identification number	B6848Y
Number of Individuals Covered	1
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $8,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

B6848H

Policy instance

Insurance contract or identification number	B6848H
Number of Individuals Covered	2
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $11,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

B6848F

Policy instance

Insurance contract or identification number	B6848F
Number of Individuals Covered	0
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $2,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00411754

Policy instance

Insurance contract or identification number	00411754
Number of Individuals Covered	249
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 )

Policy contract number

31588Y

Policy instance

Insurance contract or identification number	31588Y
Number of Individuals Covered	240
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $1,036,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

31588H

Policy instance

Insurance contract or identification number	31588H
Number of Individuals Covered	140
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $877,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 )

Policy contract number

31588Y

Policy instance

Insurance contract or identification number	31588Y
Number of Individuals Covered	236
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $1,014,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00411754

Policy instance

Insurance contract or identification number	00411754
Number of Individuals Covered	252
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $97,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

31588F

Policy instance

Insurance contract or identification number	31588F
Number of Individuals Covered	52
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $49,210
Total amount of fees paid to insurance company	USD $1,555
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $352,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,210
Amount paid for insurance broker fees	1555
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	VERACITY BENEFIT DESIGNS INC.

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00411754

Policy instance

Insurance contract or identification number	00411754
Number of Individuals Covered	248
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $353
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

31588F

Policy instance

Insurance contract or identification number	31588F
Number of Individuals Covered	78
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $52,436
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $430,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

31588H

Policy instance

Insurance contract or identification number	31588H
Number of Individuals Covered	165
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $880,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 )

Policy contract number

31588Y

Policy instance

Insurance contract or identification number	31588Y
Number of Individuals Covered	208
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $848,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00411754

Policy instance

Insurance contract or identification number	00411754
Number of Individuals Covered	389
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

31588F

Policy instance

Insurance contract or identification number	31588F
Number of Individuals Covered	94
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $77,953
Welfare Benefit Premiums Paid to Carrier	USD $429,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $77,953
Insurance broker organization code?	3
Insurance broker name	VERACITY BENEFIT DESIGNS INC.

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

31588H

Policy instance

Insurance contract or identification number	31588H
Number of Individuals Covered	164
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Welfare Benefit Premiums Paid to Carrier	USD $778,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 )

Policy contract number

31588Y

Policy instance

Insurance contract or identification number	31588Y
Number of Individuals Covered	204
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Welfare Benefit Premiums Paid to Carrier	USD $868,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	COMMUNITY SERVICES FOR EVERY1 INC
Employer identification number (EIN):	161317369
NAIC Classification:	624100
NAIC Description:	Individual and Family Services

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1987-02-10
Company Identification Number:	1143562
Legal Registered Office Address:	ATTN: MINDY CERVONI 180 OAK STREET BUFFALO United States of America (USA) 14203