ANDROSCOGGIN SAVINGS BANK has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ANDROSCOGGIN BANK GROUP BENEFIT PLAN
| 2023: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2023 form 5500 responses |
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| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 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: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 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: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 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: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 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 |
| 2018: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2015 form 5500 responses |
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| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-07-01 | Type of plan entity | Single employer plan |
| 2012-07-01 | Submission has been amended | Yes |
| 2012-07-01 | This submission is the final filing | No |
| 2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-07-01 | Plan is a collectively bargained plan | No |
| 2012-07-01 | Plan funding arrangement – Insurance | Yes |
| 2012-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-07-01 | Type of plan entity | Single employer plan |
| 2011-07-01 | Submission has been amended | No |
| 2011-07-01 | This submission is the final filing | No |
| 2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-07-01 | Plan is a collectively bargained plan | No |
| 2011-07-01 | Plan funding arrangement – Insurance | Yes |
| 2011-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-07-01 | Type of plan entity | Single employer plan |
| 2009-07-01 | Submission has been amended | No |
| 2009-07-01 | This submission is the final filing | No |
| 2009-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-07-01 | Plan is a collectively bargained plan | No |
| 2009-07-01 | Plan funding arrangement – Insurance | Yes |
| 2009-07-01 | Plan benefit arrangement – Insurance | Yes |
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 940959 |
| Policy instance | 12 |
| Insurance contract or identification number | 940959 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2023-10-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $359 | | Total amount of fees paid to insurance company | USD $73 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $2,393 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30093553 |
| Policy instance | 1 |
| Insurance contract or identification number | 30093553 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $1,132 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,912 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 956067 |
| Policy instance | 2 |
| Insurance contract or identification number | 956067 | | Number of Individuals Covered | 212 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $10,918 | | Total amount of fees paid to insurance company | USD $4,412 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $145,459 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 956068 |
| Policy instance | 3 |
| Insurance contract or identification number | 956068 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $9,976 | | Total amount of fees paid to insurance company | USD $1,941 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $66,507 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 112129 |
| Policy instance | 4 |
| Insurance contract or identification number | 112129 | | Number of Individuals Covered | 211 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $49,842 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,272,202 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 112130 |
| Policy instance | 5 |
| Insurance contract or identification number | 112130 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $7,053 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $179,921 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 112131 |
| Policy instance | 6 |
| Insurance contract or identification number | 112131 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $26,862 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $657,520 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 112132 |
| Policy instance | 7 |
| Insurance contract or identification number | 112132 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $9,142 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $206,085 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 12133 |
| Policy instance | 8 |
| Insurance contract or identification number | 12133 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $20 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,697 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0791491 |
| Policy instance | 9 |
| Insurance contract or identification number | R0791491 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $1,190 | | Total amount of fees paid to insurance company | USD $2 | | Other welfare benefits provided | CRITICAL ILLNESS & ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $14,661 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 940960 |
| Policy instance | 10 |
| Insurance contract or identification number | 940960 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2023-10-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $318 | | Total amount of fees paid to insurance company | USD $106 | | Other welfare benefits provided | HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $2,120 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 940958 |
| Policy instance | 11 |
| Insurance contract or identification number | 940958 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2023-10-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $151 | | Total amount of fees paid to insurance company | USD $53 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,579 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 956068 |
| Policy instance | 3 |
| Insurance contract or identification number | 956068 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,910 | | Total amount of fees paid to insurance company | USD $1,786 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $59,397 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0791491 |
| Policy instance | 4 |
| Insurance contract or identification number | R0791491 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,020 | | Total amount of fees paid to insurance company | USD $2 | | Other welfare benefits provided | CRITICAL ILLNESS & ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $25,949 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 112129 |
| Policy instance | 5 |
| Insurance contract or identification number | 112129 | | Number of Individuals Covered | 254 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $36,074 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,179,501 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 112130 |
| Policy instance | 6 |
| Insurance contract or identification number | 112130 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,237 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $183,168 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 112131 |
| Policy instance | 7 |
| Insurance contract or identification number | 112131 | | Number of Individuals Covered | 90 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $14,714 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $491,259 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 112132 |
| Policy instance | 8 |
| Insurance contract or identification number | 112132 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,051 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $99,717 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 956067 |
| Policy instance | 2 |
| Insurance contract or identification number | 956067 | | Number of Individuals Covered | 211 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $10,667 | | Total amount of fees paid to insurance company | USD $4,268 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $138,387 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30093553 |
| Policy instance | 1 |
| Insurance contract or identification number | 30093553 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,467 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,380 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0791491 |
| Policy instance | 5 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 956068 |
| Policy instance | 4 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 956067 |
| Policy instance | 3 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30093553 |
| Policy instance | 2 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0619960 |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0619960 |
| Policy instance | 1 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30093553 |
| Policy instance | 2 |
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | AL00005878 |
| Policy instance | 3 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0791491 |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0619960 |
| Policy instance | 1 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30026008 |
| Policy instance | 2 |
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | AL00005878 |
| Policy instance | 3 |
| ANTHEM HEALTH PLANS OF MAINE, INC. (National Association of Insurance Commissioners NAIC id number: 52618 ) |
| Policy contract number | 00C129 |
| Policy instance | 4 |
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | AL00005878 |
| Policy instance | 3 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30026008 |
| Policy instance | 2 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0619960 |
| Policy instance | 1 |
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | AL00005878 |
| Policy instance | 3 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30026008 |
| Policy instance | 2 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0619960 |
| Policy instance | 1 |
