401k Plan data: PINES HEALTH SERVICES WELFARE BENEFIT PLAN plan

PINES HEALTH SERVICES WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	PINES HEALTH SERVICES WELFARE BENEFIT PLAN
Plan identification number	501

PINES HEALTH SERVICES WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

PINES HEALTH SERVICES has sponsored the creation of one or more 401k plans.

Company Name: PINES HEALTH SERVICES

Employer identification number (EIN): 010376890

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Additional information about PINES HEALTH SERVICES

Jurisdiction of Incorporation: Maine Bureau of Corporations, Elections & Commissions

Incorporation Date:

Company Identification Number: 19820037ND

More information about PINES HEALTH SERVICES

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PINES HEALTH SERVICES WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 KRIS A. DOODY 2023-07-27 KRIS A. DOODY 2023-07-27
501 2021-01-01 KRIS A. DOODY 2022-07-25
501 2020-01-01 KRIS A. DOODY 2021-07-13
501 2019-01-01 KRIS A. DOODY 2021-07-13
501 2018-01-01 KRIS A. DOODY 2021-07-13
501 2017-01-01 KRIS A. DOODY 2021-07-13
501 2016-01-01 KRIS A. DOODY 2021-07-13
501 2015-01-01 KRIS A. DOODY 2021-07-13
501 2014-01-01 KRIS A. DOODY 2021-07-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	KRIS A. DOODY	2023-07-27	KRIS A. DOODY	2023-07-27
501	2021-01-01	KRIS A. DOODY	2022-07-25
501	2020-01-01	KRIS A. DOODY	2021-07-13
501	2019-01-01	KRIS A. DOODY	2021-07-13
501	2018-01-01	KRIS A. DOODY	2021-07-13
501	2017-01-01	KRIS A. DOODY	2021-07-13
501	2016-01-01	KRIS A. DOODY	2021-07-13
501	2015-01-01	KRIS A. DOODY	2021-07-13
501	2014-01-01	KRIS A. DOODY	2021-07-13

Plan Statistics for PINES HEALTH SERVICES WELFARE BENEFIT PLAN

401k plan membership statisitcs for PINES HEALTH SERVICES WELFARE BENEFIT PLAN

Measure Date Value
2022: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 116
Total of all active and inactive participants 2022-01-01 116
2021: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 115
Total of all active and inactive participants 2021-01-01 115
2020: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 101
Number of retired or separated participants receiving benefits 2020-01-01 1
Total of all active and inactive participants 2020-01-01 102
2019: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 113
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 113
Number of retired or separated participants receiving benefits 2019-01-01 1
Total of all active and inactive participants 2019-01-01 114
2018: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 121
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 106
Number of retired or separated participants receiving benefits 2018-01-01 1
Total of all active and inactive participants 2018-01-01 107
2017: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 124
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 119
Number of retired or separated participants receiving benefits 2017-01-01 1
Total of all active and inactive participants 2017-01-01 120
2016: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 125
Number of retired or separated participants receiving benefits 2016-01-01 1
Total of all active and inactive participants 2016-01-01 126
2015: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 114
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 112
Total of all active and inactive participants 2015-01-01 112
2014: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 108
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 109
Total of all active and inactive participants 2014-01-01 109

Measure	Date	Value
2022: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	116
Total of all active and inactive participants	2022-01-01	116
2021: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	115
Total of all active and inactive participants	2021-01-01	115
2020: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	101
Number of retired or separated participants receiving benefits	2020-01-01	1
Total of all active and inactive participants	2020-01-01	102
2019: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	113
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	113
Number of retired or separated participants receiving benefits	2019-01-01	1
Total of all active and inactive participants	2019-01-01	114
2018: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	106
Number of retired or separated participants receiving benefits	2018-01-01	1
Total of all active and inactive participants	2018-01-01	107
2017: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	124
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	119
Number of retired or separated participants receiving benefits	2017-01-01	1
Total of all active and inactive participants	2017-01-01	120
2016: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	125
Number of retired or separated participants receiving benefits	2016-01-01	1
Total of all active and inactive participants	2016-01-01	126
2015: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	112
Total of all active and inactive participants	2015-01-01	112
2014: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	108
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	109
Total of all active and inactive participants	2014-01-01	109

Form 5500 Responses for PINES HEALTH SERVICES WELFARE BENEFIT PLAN

2022: PINES HEALTH SERVICES WELFARE 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 benefit arrangement – Insurance	Yes
2021: PINES HEALTH SERVICES WELFARE 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 benefit arrangement – Insurance	Yes
2020: PINES HEALTH SERVICES WELFARE 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 benefit arrangement – Insurance	Yes
2019: PINES HEALTH SERVICES WELFARE 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 benefit arrangement – Insurance	Yes
2018: PINES HEALTH SERVICES WELFARE 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 benefit arrangement – Insurance	Yes
2017: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: PINES HEALTH SERVICES WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	First time form 5500 has been submitted	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

RED TREE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 13646 )

Policy contract number

000960661

Policy instance

Insurance contract or identification number	000960661
Number of Individuals Covered	93
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $643
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $559
Insurance broker organization code?	3

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95517 )

Policy contract number

0176078HNO

Policy instance

Insurance contract or identification number	0176078HNO
Number of Individuals Covered	79
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $21,864
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,015,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,864
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

759154

Policy instance

Insurance contract or identification number	759154
Number of Individuals Covered	115
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,733
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,733
Insurance broker organization code?	3

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060661

Policy instance

Insurance contract or identification number	000060661
Number of Individuals Covered	172
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,680
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,611
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0176078

Policy instance

Insurance contract or identification number	0176078
Number of Individuals Covered	88
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $19,240
Total amount of fees paid to insurance company	USD $2,500
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $874,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,240
Amount paid for insurance broker fees	2500
Additional information about fees paid to insurance broker	2022 Q1 GROW WITH US NEW BUSINESS INCENTIVE RISK
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080814

Policy instance

Insurance contract or identification number	080814
Number of Individuals Covered	27
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,811
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $285,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,811
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

072924

Policy instance

Insurance contract or identification number	072924
Number of Individuals Covered	77
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $14,871
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $730,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,871
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080813

Policy instance

Insurance contract or identification number	080813
Number of Individuals Covered	59
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $11,780
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $579,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,780
Insurance broker organization code?	3

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060661

Policy instance

Insurance contract or identification number	000060661
Number of Individuals Covered	161
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,562
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,618
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

759154

Policy instance

Insurance contract or identification number	759154
Number of Individuals Covered	115
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,624
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,624
Insurance broker organization code?	3

RED TREE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 13646 )

Policy contract number

000960661

Policy instance

Insurance contract or identification number	000960661
Number of Individuals Covered	83
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $619
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $538
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

759154

Policy instance

Insurance contract or identification number	759154
Number of Individuals Covered	117
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $8,121
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,749
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

072924

Policy instance

Insurance contract or identification number	072924
Number of Individuals Covered	59
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $12,672
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $491,316
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,362
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080814

Policy instance

Insurance contract or identification number	080814
Number of Individuals Covered	23
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,265
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $204,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,890
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080813

Policy instance

Insurance contract or identification number	080813
Number of Individuals Covered	98
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $17,840
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $691,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,180
Insurance broker organization code?	3

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060661

Policy instance

Insurance contract or identification number	000060661
Number of Individuals Covered	171
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,160
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,150
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080813

Policy instance

Insurance contract or identification number	080813
Number of Individuals Covered	107
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $19,125
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $617,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,125
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400199029

Policy instance

Insurance contract or identification number	000400199029
Number of Individuals Covered	72
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,091
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $10,913
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,091
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199028

Policy instance

Insurance contract or identification number	000010199028
Number of Individuals Covered	130
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,544
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,544
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199030

Policy instance

Insurance contract or identification number	000010199030
Number of Individuals Covered	108
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,638
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,638
Insurance broker organization code?	3

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060661

Policy instance

Insurance contract or identification number	000060661
Number of Individuals Covered	194
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,398
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,504
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080814

Policy instance

Insurance contract or identification number	080814
Number of Individuals Covered	26
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,345
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $140,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,345
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

072924

Policy instance

Insurance contract or identification number	072924
Number of Individuals Covered	71
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $13,244
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $427,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,244
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199027

Policy instance

Insurance contract or identification number	000010199027
Number of Individuals Covered	131
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,374
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $12,052
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,374
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199030

Policy instance

Insurance contract or identification number	000010199030
Number of Individuals Covered	107
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,653
Total amount of fees paid to insurance company	USD $381
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,653
Amount paid for insurance broker fees	381
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400199029

Policy instance

Insurance contract or identification number	000400199029
Number of Individuals Covered	73
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,086
Total amount of fees paid to insurance company	USD $122
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $10,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,086
Amount paid for insurance broker fees	122
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199027

Policy instance

Insurance contract or identification number	000010199027
Number of Individuals Covered	129
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,369
Total amount of fees paid to insurance company	USD $127
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $11,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,369
Amount paid for insurance broker fees	127
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

072924

Policy instance

Insurance contract or identification number	072924
Number of Individuals Covered	42
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,590
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $216,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,590
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080814

Policy instance

Insurance contract or identification number	080814
Number of Individuals Covered	115
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $21,449
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $706,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,449
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080813

Policy instance

Insurance contract or identification number	080813
Number of Individuals Covered	40
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,243
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $271,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,243
Insurance broker organization code?	3

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060661

Policy instance

Insurance contract or identification number	000060661
Number of Individuals Covered	240
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,011
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,993
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199028

Policy instance

Insurance contract or identification number	000010199028
Number of Individuals Covered	129
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,522
Total amount of fees paid to insurance company	USD $527
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,522
Amount paid for insurance broker fees	527
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199027

Policy instance

Insurance contract or identification number	000010199027
Number of Individuals Covered	140
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,423
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $12,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,423
Insurance broker organization code?	3

HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )

Policy contract number

080815

Policy instance

Insurance contract or identification number	080815
Number of Individuals Covered	38
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,806
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $172,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,806
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080814

Policy instance

Insurance contract or identification number	080814
Number of Individuals Covered	148
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $27,730
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $823,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,730
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080813

Policy instance

Insurance contract or identification number	080813
Number of Individuals Covered	52
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $8,567
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $254,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,567
Insurance broker organization code?	3

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060661

Policy instance

Insurance contract or identification number	000060661
Number of Individuals Covered	275
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,274
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,240
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,199
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199030

Policy instance

Insurance contract or identification number	000010199030
Number of Individuals Covered	114
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,671
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,671
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199028

Policy instance

Insurance contract or identification number	000010199028
Number of Individuals Covered	139
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,527
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,527
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400199029

Policy instance

Insurance contract or identification number	000400199029
Number of Individuals Covered	77
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,222
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $12,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,222
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400199029

Policy instance

Insurance contract or identification number	000400199029
Number of Individuals Covered	83
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $1,163
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $11,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,163
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199028

Policy instance

Insurance contract or identification number	000010199028
Number of Individuals Covered	146
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $4,500
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,500
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199030

Policy instance

Insurance contract or identification number	000010199030
Number of Individuals Covered	123
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $2,667
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,850
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,667
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080813

Policy instance

Insurance contract or identification number	080813
Number of Individuals Covered	57
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $8,416
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $259,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,416
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080814

Policy instance

Insurance contract or identification number	080814
Number of Individuals Covered	171
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $24,861
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $767,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,861
Insurance broker organization code?	3

HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )

Policy contract number

080815

Policy instance

Insurance contract or identification number	080815
Number of Individuals Covered	31
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $5,601
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $172,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,601
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199027

Policy instance

Insurance contract or identification number	000010199027
Number of Individuals Covered	146
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $1,366
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $11,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,366
Insurance broker organization code?	3

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060661

Policy instance

Insurance contract or identification number	000060661
Number of Individuals Covered	289
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $5,740
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $99,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,552
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400199029

Policy instance

Insurance contract or identification number	000400199029
Number of Individuals Covered	74
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,149
Total amount of fees paid to insurance company	USD $291
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $11,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,149
Amount paid for insurance broker fees	291
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199030

Policy instance

Insurance contract or identification number	000010199030
Number of Individuals Covered	116
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,665
Total amount of fees paid to insurance company	USD $1,274
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,665
Amount paid for insurance broker fees	1274
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199028

Policy instance

Insurance contract or identification number	000010199028
Number of Individuals Covered	130
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,407
Total amount of fees paid to insurance company	USD $1,723
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,407
Amount paid for insurance broker fees	1723
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060661

Policy instance

Insurance contract or identification number	000060661
Number of Individuals Covered	248
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,028
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,037
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080813

Policy instance

Insurance contract or identification number	080813
Number of Individuals Covered	52
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,036
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $235,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,036
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080814

Policy instance

Insurance contract or identification number	080814
Number of Individuals Covered	133
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $23,644
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $692,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,644
Insurance broker organization code?	3

HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )

Policy contract number

080815

Policy instance

Insurance contract or identification number	080815
Number of Individuals Covered	25
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,786
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $140,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,786
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010199027

Policy instance

Insurance contract or identification number	000010199027
Number of Individuals Covered	131
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,327
Total amount of fees paid to insurance company	USD $402
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $11,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,327
Amount paid for insurance broker fees	402
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

151014

Policy instance

Insurance contract or identification number	151014
Number of Individuals Covered	130
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $11,179
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,179
Insurance broker organization code?	3

DELTA DENTAL PLAN OF MAINE (National Association of Insurance Commissioners NAIC id number: 14369 )

Policy contract number

000060661

Policy instance

Insurance contract or identification number	000060661
Number of Individuals Covered	266
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,060
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,847
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080813

Policy instance

Insurance contract or identification number	080813
Number of Individuals Covered	46
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $48,242
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,269,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,242
Insurance broker organization code?	3

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )

Policy contract number

080814

Policy instance

Insurance contract or identification number	080814
Number of Individuals Covered	160
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $34,823
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $916,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,823
Insurance broker organization code?	3

HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )

Policy contract number

080815

Policy instance

Insurance contract or identification number	080815
Number of Individuals Covered	21
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,731
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $126,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,731
Insurance broker organization code?	3

Potentially related plans

PINES HEALTHCARE CENTER 401(K) PLAN [EIN = 431620600]

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See full terms and conditions

Company Name:	PINES HEALTH SERVICES
Employer identification number (EIN):	010376890
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)

Jurisdiction of Incorporation:	Maine Bureau of Corporations, Elections & Commissions
Incorporation Date:
Company Identification Number:	19820037ND