BALLY RIBBON MILLS INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan GROUP MEDICAL POLICY OF BALLY RIBBON MILLS
| Measure | Date | Value |
|---|
| 2022: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 197 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 193 |
| Total of all active and inactive participants | 2022-01-01 | 193 |
| Total participants | 2022-01-01 | 193 |
| 2021: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 230 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 197 |
| Total of all active and inactive participants | 2021-01-01 | 197 |
| Total participants | 2021-01-01 | 197 |
| 2020: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 227 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 230 |
| Total of all active and inactive participants | 2020-01-01 | 230 |
| Total participants | 2020-01-01 | 230 |
| 2019: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 223 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 227 |
| Total of all active and inactive participants | 2019-01-01 | 227 |
| Total participants | 2019-01-01 | 227 |
| 2017: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 235 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 218 |
| Total of all active and inactive participants | 2017-01-01 | 218 |
| Total participants | 2017-01-01 | 218 |
| 2016: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 236 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 235 |
| Total of all active and inactive participants | 2016-01-01 | 235 |
| Total participants | 2016-01-01 | 235 |
| 2015: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 228 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 235 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 1 |
| Total of all active and inactive participants | 2015-01-01 | 236 |
| Total participants | 2015-01-01 | 236 |
| 2014: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 229 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 227 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 1 |
| Total of all active and inactive participants | 2014-01-01 | 228 |
| Total participants | 2014-01-01 | 228 |
| 2013: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 224 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 229 |
| Total of all active and inactive participants | 2013-01-01 | 229 |
| Total participants | 2013-01-01 | 229 |
| 2012: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 226 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 224 |
| Total of all active and inactive participants | 2012-01-01 | 224 |
| Total participants | 2012-01-01 | 224 |
| 2011: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 216 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 226 |
| Total of all active and inactive participants | 2011-01-01 | 226 |
| Total participants | 2011-01-01 | 226 |
| 2009: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 239 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 215 |
| Total of all active and inactive participants | 2009-01-01 | 215 |
| Total participants | 2009-01-01 | 215 |
| 2022: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 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: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 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: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 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: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 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 |
| 2017: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 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: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 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: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 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: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 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: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 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: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: GROUP MEDICAL POLICY OF BALLY RIBBON MILLS 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0491978 |
| Policy instance | 4 |
| Insurance contract or identification number | 0491978 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $898 | | 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 | 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 $10,598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 ) |
| Policy contract number | 801890 |
| Policy instance | 3 |
| Insurance contract or identification number | 801890 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $7,626 | | Total amount of fees paid to insurance company | USD $1,525 | | 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 $75,902 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 407754 0010 |
| Policy instance | 2 |
| Insurance contract or identification number | 407754 0010 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | 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 $308,525 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 1 |
| Insurance contract or identification number | 00515245 | | Number of Individuals Covered | 322 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $105,390 | | 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 | Yes | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 1 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 2 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 10112039 |
| Policy instance | 3 |
| STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 ) |
| Policy contract number | 801890 |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0491978 |
| Policy instance | 5 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 1 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 2 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 10112039 |
| Policy instance | 3 |
| STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 ) |
| Policy contract number | 801890 |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0491978 |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0491978 |
| Policy instance | 4 |
| AVALON INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 12358 ) |
| Policy contract number | 00515245 |
| Policy instance | 3 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 2 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 1 |
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | GLIUME000841 |
| Policy instance | 3 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 2 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 1 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 1 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 2 |
| AVALON INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 12358 ) |
| Policy contract number | 00515245 |
| Policy instance | 3 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 3 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00515245 |
| Policy instance | 1 |
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00515245 |
| Policy instance | 2 |
| AVALON INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 12358 ) |
| Policy contract number | 00515245 |
| Policy instance | 4 |
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 136784 |
| Policy instance | 1 |
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 00515245 |
| Policy instance | 2 |
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 805772 |
| Policy instance | 3 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | US00628V |
| Policy instance | 1 |
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 805772 |
| Policy instance | 3 |
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 00515245 |
| Policy instance | 2 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | US00628V |
| Policy instance | 1 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | US00628V |
| Policy instance | 1 |
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 00515245 |
| Policy instance | 2 |
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 805772 |
| Policy instance | 3 |
