401k Plan data: EMPLOYEE WELFARE BENEFIT PLAN plan

EMPLOYEE WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	EMPLOYEE WELFARE BENEFIT PLAN
Plan identification number	501

EMPLOYEE WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

PENNSYLVANIA LUMBERMENS MUTUAL INSURANCE COMPANY has sponsored the creation of one or more 401k plans.

Company Name: PENNSYLVANIA LUMBERMENS MUTUAL INSURANCE COMPANY

Employer identification number (EIN): 230959220

NAIC Classification: 524150

Additional information about PENNSYLVANIA LUMBERMENS MUTUAL INSURANCE COMPANY

Jurisdiction of Incorporation: Georgia Department of States Corporations Division

Incorporation Date:

Company Identification Number: 572520

More information about PENNSYLVANIA LUMBERMENS MUTUAL INSURANCE COMPANY

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-06-01 HAROLD JAMISON
501 2022-06-01
501 2022-06-01 HAROLD JAMISON
501 2021-06-01
501 2021-06-01 HAROLD JAMISON
501 2020-06-01
501 2019-06-01
501 2018-06-01 HAROLD JAMISON 2020-01-14
501 2017-06-01 HAROLD JAMISON 2020-01-14
501 2016-06-01 RICHARD MILLER
501 2015-06-01 HAROLD JAMISON
501 2014-06-01 PAUL E. SELLS, JR. PAUL E. SELLS, JR. 2016-02-24
501 2013-06-01 PAUL E. SELLS, JR. PAUL E. SELLS, JR. 2015-03-11
501 2012-06-01 PAUL E. SELLS, JR. EILEEN M. SLEUTARIS 2013-12-19
501 2011-06-01 PAUL E. SELLS, JR. EILEEN M. SLEUTARIS 2013-01-25
501 2009-06-01 PAUL E SELLS JR EILEEN M. SLEUTARIS 2011-02-10

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-06-01	HAROLD JAMISON
501	2022-06-01
501	2022-06-01	HAROLD JAMISON
501	2021-06-01
501	2021-06-01	HAROLD JAMISON
501	2020-06-01
501	2019-06-01
501	2018-06-01	HAROLD JAMISON	2020-01-14
501	2017-06-01	HAROLD JAMISON	2020-01-14
501	2016-06-01	RICHARD MILLER
501	2015-06-01	HAROLD JAMISON
501	2014-06-01	PAUL E. SELLS, JR.		PAUL E. SELLS, JR.	2016-02-24
501	2013-06-01	PAUL E. SELLS, JR.		PAUL E. SELLS, JR.	2015-03-11
501	2012-06-01	PAUL E. SELLS, JR.		EILEEN M. SLEUTARIS	2013-12-19
501	2011-06-01	PAUL E. SELLS, JR.		EILEEN M. SLEUTARIS	2013-01-25
501	2009-06-01	PAUL E SELLS JR		EILEEN M. SLEUTARIS	2011-02-10

Plan Statistics for EMPLOYEE WELFARE BENEFIT PLAN

401k plan membership statisitcs for EMPLOYEE WELFARE BENEFIT PLAN

Measure Date Value
2022: EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-06-01 160
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 230
Number of retired or separated participants receiving benefits 2022-06-01 0
Number of other retired or separated participants entitled to future benefits 2022-06-01 0
Total of all active and inactive participants 2022-06-01 230
2021: EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-06-01 122
Total number of active participants reported on line 7a of the Form 5500 2021-06-01 160
Number of retired or separated participants receiving benefits 2021-06-01 0
Number of other retired or separated participants entitled to future benefits 2021-06-01 0
Total of all active and inactive participants 2021-06-01 160
2020: EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-06-01 116
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 122
Number of retired or separated participants receiving benefits 2020-06-01 0
Number of other retired or separated participants entitled to future benefits 2020-06-01 0
Total of all active and inactive participants 2020-06-01 122
2019: EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-06-01 145
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 116
Number of retired or separated participants receiving benefits 2019-06-01 0
Number of other retired or separated participants entitled to future benefits 2019-06-01 0
Total of all active and inactive participants 2019-06-01 116
2018: EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-06-01 137
Total number of active participants reported on line 7a of the Form 5500 2018-06-01 145
Number of retired or separated participants receiving benefits 2018-06-01 0
Number of other retired or separated participants entitled to future benefits 2018-06-01 0
Total of all active and inactive participants 2018-06-01 145
2017: EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-06-01 143
Total number of active participants reported on line 7a of the Form 5500 2017-06-01 137
Number of retired or separated participants receiving benefits 2017-06-01 0
Number of other retired or separated participants entitled to future benefits 2017-06-01 0
Total of all active and inactive participants 2017-06-01 137
2016: EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-06-01 142
Total number of active participants reported on line 7a of the Form 5500 2016-06-01 143
Number of retired or separated participants receiving benefits 2016-06-01 0
Number of other retired or separated participants entitled to future benefits 2016-06-01 0
Total of all active and inactive participants 2016-06-01 143
2015: EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-06-01 164
Total number of active participants reported on line 7a of the Form 5500 2015-06-01 142
Number of retired or separated participants receiving benefits 2015-06-01 95
Number of other retired or separated participants entitled to future benefits 2015-06-01 0
Total of all active and inactive participants 2015-06-01 237
Total participants 2015-06-01 237
2014: EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-06-01 193
Total number of active participants reported on line 7a of the Form 5500 2014-06-01 164
Number of retired or separated participants receiving benefits 2014-06-01 102
Number of other retired or separated participants entitled to future benefits 2014-06-01 0
Total of all active and inactive participants 2014-06-01 266
2013: EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-06-01 194
Total number of active participants reported on line 7a of the Form 5500 2013-06-01 144
Number of retired or separated participants receiving benefits 2013-06-01 49
Number of other retired or separated participants entitled to future benefits 2013-06-01 0
Total of all active and inactive participants 2013-06-01 193
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-06-01 0
Total participants 2013-06-01 193
2012: EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-06-01 187
Total number of active participants reported on line 7a of the Form 5500 2012-06-01 142
Number of retired or separated participants receiving benefits 2012-06-01 52
Number of other retired or separated participants entitled to future benefits 2012-06-01 0
Total of all active and inactive participants 2012-06-01 194
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-06-01 0
Total participants 2012-06-01 194
2011: EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-06-01 174
Total number of active participants reported on line 7a of the Form 5500 2011-06-01 135
Number of retired or separated participants receiving benefits 2011-06-01 52
Number of other retired or separated participants entitled to future benefits 2011-06-01 0
Total of all active and inactive participants 2011-06-01 187
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-06-01 0
Total participants 2011-06-01 187
2009: EMPLOYEE WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-06-01 197
Total number of active participants reported on line 7a of the Form 5500 2009-06-01 182
Number of retired or separated participants receiving benefits 2009-06-01 0
Number of other retired or separated participants entitled to future benefits 2009-06-01 0
Total of all active and inactive participants 2009-06-01 182

Measure	Date	Value
2022: EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-06-01	160
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	230
Number of retired or separated participants receiving benefits	2022-06-01	0
Number of other retired or separated participants entitled to future benefits	2022-06-01	0
Total of all active and inactive participants	2022-06-01	230
2021: EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-06-01	122
Total number of active participants reported on line 7a of the Form 5500	2021-06-01	160
Number of retired or separated participants receiving benefits	2021-06-01	0
Number of other retired or separated participants entitled to future benefits	2021-06-01	0
Total of all active and inactive participants	2021-06-01	160
2020: EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-06-01	116
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	122
Number of retired or separated participants receiving benefits	2020-06-01	0
Number of other retired or separated participants entitled to future benefits	2020-06-01	0
Total of all active and inactive participants	2020-06-01	122
2019: EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-06-01	145
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	116
Number of retired or separated participants receiving benefits	2019-06-01	0
Number of other retired or separated participants entitled to future benefits	2019-06-01	0
Total of all active and inactive participants	2019-06-01	116
2018: EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-06-01	137
Total number of active participants reported on line 7a of the Form 5500	2018-06-01	145
Number of retired or separated participants receiving benefits	2018-06-01	0
Number of other retired or separated participants entitled to future benefits	2018-06-01	0
Total of all active and inactive participants	2018-06-01	145
2017: EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-06-01	143
Total number of active participants reported on line 7a of the Form 5500	2017-06-01	137
Number of retired or separated participants receiving benefits	2017-06-01	0
Number of other retired or separated participants entitled to future benefits	2017-06-01	0
Total of all active and inactive participants	2017-06-01	137
2016: EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-06-01	142
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	143
Number of retired or separated participants receiving benefits	2016-06-01	0
Number of other retired or separated participants entitled to future benefits	2016-06-01	0
Total of all active and inactive participants	2016-06-01	143
2015: EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-06-01	164
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	142
Number of retired or separated participants receiving benefits	2015-06-01	95
Number of other retired or separated participants entitled to future benefits	2015-06-01	0
Total of all active and inactive participants	2015-06-01	237
Total participants	2015-06-01	237
2014: EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-06-01	193
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	164
Number of retired or separated participants receiving benefits	2014-06-01	102
Number of other retired or separated participants entitled to future benefits	2014-06-01	0
Total of all active and inactive participants	2014-06-01	266
2013: EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-06-01	194
Total number of active participants reported on line 7a of the Form 5500	2013-06-01	144
Number of retired or separated participants receiving benefits	2013-06-01	49
Number of other retired or separated participants entitled to future benefits	2013-06-01	0
Total of all active and inactive participants	2013-06-01	193
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-06-01	0
Total participants	2013-06-01	193
2012: EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-06-01	187
Total number of active participants reported on line 7a of the Form 5500	2012-06-01	142
Number of retired or separated participants receiving benefits	2012-06-01	52
Number of other retired or separated participants entitled to future benefits	2012-06-01	0
Total of all active and inactive participants	2012-06-01	194
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-06-01	0
Total participants	2012-06-01	194
2011: EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-06-01	174
Total number of active participants reported on line 7a of the Form 5500	2011-06-01	135
Number of retired or separated participants receiving benefits	2011-06-01	52
Number of other retired or separated participants entitled to future benefits	2011-06-01	0
Total of all active and inactive participants	2011-06-01	187
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-06-01	0
Total participants	2011-06-01	187
2009: EMPLOYEE WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-06-01	197
Total number of active participants reported on line 7a of the Form 5500	2009-06-01	182
Number of retired or separated participants receiving benefits	2009-06-01	0
Number of other retired or separated participants entitled to future benefits	2009-06-01	0
Total of all active and inactive participants	2009-06-01	182

Form 5500 Responses for EMPLOYEE WELFARE BENEFIT PLAN

2022: EMPLOYEE WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	Submission has been amended	No
2022-06-01	This submission is the final filing	No
2022-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-06-01	Plan is a collectively bargained plan	No
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: EMPLOYEE WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-06-01	Type of plan entity	Single employer plan
2021-06-01	Submission has been amended	No
2021-06-01	This submission is the final filing	No
2021-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-06-01	Plan is a collectively bargained plan	No
2021-06-01	Plan funding arrangement – Insurance	Yes
2021-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-06-01	Plan benefit arrangement – Insurance	Yes
2021-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: EMPLOYEE WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Submission has been amended	No
2020-06-01	This submission is the final filing	No
2020-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-06-01	Plan is a collectively bargained plan	No
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	Submission has been amended	No
2019-06-01	This submission is the final filing	No
2019-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-06-01	Plan is a collectively bargained plan	No
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: EMPLOYEE WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-06-01	Type of plan entity	Single employer plan
2018-06-01	Submission has been amended	No
2018-06-01	This submission is the final filing	No
2018-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-06-01	Plan is a collectively bargained plan	No
2018-06-01	Plan funding arrangement – Insurance	Yes
2018-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-06-01	Plan benefit arrangement – Insurance	Yes
2018-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: EMPLOYEE WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-06-01	Type of plan entity	Single employer plan
2017-06-01	Submission has been amended	No
2017-06-01	This submission is the final filing	No
2017-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-06-01	Plan is a collectively bargained plan	No
2017-06-01	Plan funding arrangement – Insurance	Yes
2017-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-06-01	Plan benefit arrangement – Insurance	Yes
2017-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: EMPLOYEE WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-06-01	Type of plan entity	Single employer plan
2016-06-01	Submission has been amended	No
2016-06-01	This submission is the final filing	No
2016-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-06-01	Plan is a collectively bargained plan	No
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: EMPLOYEE WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	Submission has been amended	No
2015-06-01	This submission is the final filing	No
2015-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-06-01	Plan is a collectively bargained plan	No
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes
2014: EMPLOYEE WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	Submission has been amended	No
2014-06-01	This submission is the final filing	No
2014-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-06-01	Plan is a collectively bargained plan	No
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes
2013: EMPLOYEE WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-06-01	Type of plan entity	Single employer plan
2013-06-01	Submission has been amended	No
2013-06-01	This submission is the final filing	No
2013-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-06-01	Plan is a collectively bargained plan	No
2013-06-01	Plan funding arrangement – Insurance	Yes
2013-06-01	Plan benefit arrangement – Insurance	Yes
2012: EMPLOYEE WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-06-01	Type of plan entity	Single employer plan
2012-06-01	Submission has been amended	No
2012-06-01	This submission is the final filing	No
2012-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-06-01	Plan is a collectively bargained plan	No
2012-06-01	Plan funding arrangement – Insurance	Yes
2012-06-01	Plan benefit arrangement – Insurance	Yes
2011: EMPLOYEE WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-06-01	Type of plan entity	Single employer plan
2011-06-01	Submission has been amended	No
2011-06-01	This submission is the final filing	No
2011-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-06-01	Plan is a collectively bargained plan	No
2011-06-01	Plan funding arrangement – Insurance	Yes
2011-06-01	Plan benefit arrangement – Insurance	Yes
2009: EMPLOYEE WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-06-01	Type of plan entity	Single employer plan
2009-06-01	Submission has been amended	No
2009-06-01	This submission is the final filing	No
2009-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-06-01	Plan is a collectively bargained plan	No
2009-06-01	Plan funding arrangement – Insurance	Yes
2009-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	4
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	0000006193
Policy instance	3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	894100G
Policy instance	2
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	922478 000/099
Policy instance	1
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	6193
Policy instance	1
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	894100G
Policy instance	2
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	922478 000/099
Policy instance	4
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	6193
Policy instance	1
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	550606
Policy instance	4
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	922478 000/099
Policy instance	2
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	550606
Policy instance	4
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	6193
Policy instance	3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	1
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	922478 000/099
Policy instance	2
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	6193
Policy instance	2
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	550606
Policy instance	3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	1
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	6193
Policy instance	2
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	1
UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )
Policy contract number	258820
Policy instance	4
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	01-017146-00
Policy instance	3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number	812
Policy instance	4
UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )
Policy contract number	258820 & SUBS
Policy instance	3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	6193
Policy instance	2
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	1
UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )
Policy contract number	258820 & SUBS
Policy instance	4
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	6193
Policy instance	2
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	1
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number	155768
Policy instance	3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	1
UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )
Policy contract number	253729
Policy instance	5
UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )
Policy contract number	258820 & SUBS
Policy instance	4
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	6193
Policy instance	2
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number	4421
Policy instance	3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	6193
Policy instance	2
UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )
Policy contract number	253729
Policy instance	5
UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )
Policy contract number	258820 & SUBS
Policy instance	4
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number	4421
Policy instance	3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	1
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	1
UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )
Policy contract number	253729
Policy instance	5
UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )
Policy contract number	258820 & SUBS
Policy instance	4
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number	4421
Policy instance	3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	6193
Policy instance	2
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number	6193
Policy instance	1
UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )
Policy contract number	253729
Policy instance	5
UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )
Policy contract number	258820 & SUBS
Policy instance	4
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number	4421
Policy instance	3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54704 )
Policy contract number	6193
Policy instance	2

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Company Name:	PENNSYLVANIA LUMBERMENS MUTUAL INSURANCE COMPANY
Employer identification number (EIN):	230959220
NAIC Classification:	524150

Jurisdiction of Incorporation:	Georgia Department of States Corporations Division
Incorporation Date:
Company Identification Number:	572520