LIFE LINE HOSPITAL has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan LIFE LINE HOSPITAL GROUP HEALTH PLAN
| Measure | Date | Value |
|---|
| 2016: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-05-01 | 80 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-05-01 | 68 |
| Total of all active and inactive participants | 2016-05-01 | 68 |
| Total participants | 2016-05-01 | 68 |
| 2015: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-05-01 | 84 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-05-01 | 79 |
| Number of retired or separated participants receiving benefits | 2015-05-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2015-05-01 | 0 |
| Total of all active and inactive participants | 2015-05-01 | 80 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2015-05-01 | 0 |
| Total participants | 2015-05-01 | 80 |
| Number of participants with account balances | 2015-05-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2015-05-01 | 0 |
| 2014: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-05-01 | 124 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-05-01 | 81 |
| Number of retired or separated participants receiving benefits | 2014-05-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2014-05-01 | 1 |
| Total of all active and inactive participants | 2014-05-01 | 84 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2014-05-01 | 0 |
| Total participants | 2014-05-01 | 84 |
| Number of participants with account balances | 2014-05-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2014-05-01 | 0 |
| 2013: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-05-01 | 133 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-05-01 | 118 |
| Number of retired or separated participants receiving benefits | 2013-05-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2013-05-01 | 3 |
| Total of all active and inactive participants | 2013-05-01 | 124 |
| Total participants | 2013-05-01 | 124 |
| 2012: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-05-01 | 176 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-05-01 | 127 |
| Number of retired or separated participants receiving benefits | 2012-05-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2012-05-01 | 2 |
| Total of all active and inactive participants | 2012-05-01 | 133 |
| 2011: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-05-01 | 103 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-05-01 | 176 |
| Number of retired or separated participants receiving benefits | 2011-05-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2011-05-01 | 0 |
| Total of all active and inactive participants | 2011-05-01 | 180 |
| 2016: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2016 form 5500 responses |
|---|
| 2016-05-01 | Type of plan entity | Single employer plan |
| 2016-05-01 | Plan funding arrangement – Insurance | Yes |
| 2016-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2015 form 5500 responses |
|---|
| 2015-05-01 | Type of plan entity | Single employer plan |
| 2015-05-01 | Plan funding arrangement – Insurance | Yes |
| 2015-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2014 form 5500 responses |
|---|
| 2014-05-01 | Type of plan entity | Single employer plan |
| 2014-05-01 | Plan funding arrangement – Insurance | Yes |
| 2014-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2013 form 5500 responses |
|---|
| 2013-05-01 | Type of plan entity | Single employer plan |
| 2013-05-01 | Plan funding arrangement – Insurance | Yes |
| 2013-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2012 form 5500 responses |
|---|
| 2012-05-01 | Type of plan entity | Single employer plan |
| 2012-05-01 | Submission has been amended | No |
| 2012-05-01 | This submission is the final filing | No |
| 2012-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-05-01 | Plan is a collectively bargained plan | No |
| 2012-05-01 | Plan funding arrangement – Insurance | Yes |
| 2012-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: LIFE LINE HOSPITAL GROUP HEALTH PLAN 2011 form 5500 responses |
|---|
| 2011-05-01 | Type of plan entity | Single employer plan |
| 2011-05-01 | First time form 5500 has been submitted | Yes |
| 2011-05-01 | Submission has been amended | No |
| 2011-05-01 | This submission is the final filing | No |
| 2011-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-05-01 | Plan is a collectively bargained plan | No |
| 2011-05-01 | Plan funding arrangement – Insurance | Yes |
| 2011-05-01 | Plan benefit arrangement – Insurance | Yes |
| HEALTHAMERICA OF PENNSYLVANIA, INC (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 5926020000 |
| Policy instance | 4 |
| Insurance contract or identification number | 5926020000 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $101,209 |
|
| NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 ) |
| Policy contract number | 4121 |
| Policy instance | 3 |
| Insurance contract or identification number | 4121 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,701 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000167 |
| Policy instance | 2 |
| Insurance contract or identification number | 000400001000167 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $58,751 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5451968 |
| Policy instance | 1 |
| Insurance contract or identification number | 5451968 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,681 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 ) |
| Policy contract number | 4121 |
| Policy instance | 3 |
| Insurance contract or identification number | 4121 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,323 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000167 |
| Policy instance | 2 |
| Insurance contract or identification number | 000400001000167 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of fees paid to insurance company | USD $2,173 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $70,003 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2173 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF PENNSYLVANIA |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5451968 |
| Policy instance | 1 |
| Insurance contract or identification number | 5451968 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,924 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHAMERICA OF PENNSYLVANIA, INC (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 5926020000 |
| Policy instance | 4 |
| Insurance contract or identification number | 5926020000 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $76,563 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHAMERICA OF PENNSYLVANIA, INC (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 5926020000 |
| Policy instance | 4 |
| Insurance contract or identification number | 5926020000 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $111,437 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000167 |
| Policy instance | 2 |
| Insurance contract or identification number | 000400001000167 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $7,754 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $72,291 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,754 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF PENNSYLVANIA INC. |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5451968 |
| Policy instance | 1 |
| Insurance contract or identification number | 5451968 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $1,433 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,442 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,433 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF PENNSYLVANIA INC. |
|
| CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 ) |
| Policy contract number | 51328 |
| Policy instance | 3 |
| Insurance contract or identification number | 51328 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $327 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,795 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $327 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF PENNSYLVANIA, INC. |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5451968 |
| Policy instance | 1 |
| Insurance contract or identification number | 5451968 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $2,334 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 $46,773 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,334 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF PENNSYLVANIA INC. |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 09982 |
| Policy instance | 4 |
| Insurance contract or identification number | 09982 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $8,641 | | Total amount of fees paid to insurance company | USD $56 | | Are there contracts with allocated funds for individual policies? | No | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $97,966 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,641 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 56 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES | | Insurance broker name | AXA ASSISTANCE USA |
|
| CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 ) |
| Policy contract number | 51328 |
| Policy instance | 3 |
| Insurance contract or identification number | 51328 | | Number of Individuals Covered | 199 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $405 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $8,105 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $405 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF PENNSYLVANIA, INC. |
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| CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 ) |
| Policy contract number | 5924880000 |
| Policy instance | 2 |
| Insurance contract or identification number | 5924880000 | | Number of Individuals Covered | 212 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $25,429 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 | Yes | | 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 $1,017,140 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,429 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF PENNSYLVANIA INC. |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5451968 |
| Policy instance | 1 |
| Insurance contract or identification number | 5451968 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $2,169 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 $43,285 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 ) |
| Policy contract number | 5924880000 |
| Policy instance | 2 |
| Insurance contract or identification number | 5924880000 | | Number of Individuals Covered | 249 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $23,134 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 | Yes | | 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 $993,162 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 ) |
| Policy contract number | 51328 |
| Policy instance | 3 |
| Insurance contract or identification number | 51328 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $436 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $8,720 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 09982 |
| Policy instance | 4 |
| Insurance contract or identification number | 09982 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $9,203 | | Total amount of fees paid to insurance company | USD $55 | | Are there contracts with allocated funds for individual policies? | No | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $110,327 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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