401k Plan data: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST plan

FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 401k Plan overview

Plan Name	FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST
Plan identification number	502

FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 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

FIRST ATLANTIC CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: FIRST ATLANTIC CORPORATION

Employer identification number (EIN): 010407925

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Additional information about FIRST ATLANTIC CORPORATION

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1988-11-01

Company Identification Number: 1303133

Legal Registered Office Address: 4465 e. genesee st.
Onondaga
SYRACUSE
United States of America (USA)
13214

More information about FIRST ATLANTIC CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2022-01-01 WANDA PELKEY 2023-10-13
502 2021-01-01 WANDA PELKEY 2022-10-14
502 2020-01-01 WANDA PELKEY 2021-10-12
502 2020-01-01 WANDA PELKEY 2022-11-28
502 2019-01-01 WANDA PELKEY 2020-10-13
502 2018-01-01 WANDA PELKEY 2019-10-15
502 2017-01-01
502 2016-01-01
502 2015-01-01
502 2014-01-01 WANDA PELKEY WANDA PELKEY 2015-10-14
502 2013-01-01 WANDA PELKEY WANDA PELKEY 2014-10-15
502 2012-01-01 WANDA PELKEY WANDA PELKEY 2013-10-10
502 2011-01-01 WANDA PELKEY WANDA PELKEY 2012-10-11
502 2010-01-01 WANDA PELKEY WANDA PELKEY 2011-09-22
502 2009-01-01 WANDA PELKEY WANDA PELKEY 2010-10-15

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2022-01-01	WANDA PELKEY	2023-10-13
502	2021-01-01	WANDA PELKEY	2022-10-14
502	2020-01-01	WANDA PELKEY	2021-10-12
502	2020-01-01	WANDA PELKEY	2022-11-28
502	2019-01-01	WANDA PELKEY	2020-10-13
502	2018-01-01	WANDA PELKEY	2019-10-15
502	2017-01-01
502	2016-01-01
502	2015-01-01
502	2014-01-01	WANDA PELKEY		WANDA PELKEY	2015-10-14
502	2013-01-01	WANDA PELKEY		WANDA PELKEY	2014-10-15
502	2012-01-01	WANDA PELKEY		WANDA PELKEY	2013-10-10
502	2011-01-01	WANDA PELKEY		WANDA PELKEY	2012-10-11
502	2010-01-01	WANDA PELKEY		WANDA PELKEY	2011-09-22
502	2009-01-01	WANDA PELKEY		WANDA PELKEY	2010-10-15

Plan Statistics for FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST

401k plan membership statisitcs for FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST

Measure Date Value
2022: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2022 401k membership
Total participants, beginning-of-year 2022-01-01 712
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 738
Total of all active and inactive participants 2022-01-01 738
2021: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2021 401k membership
Total participants, beginning-of-year 2021-01-01 874
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 712
Total of all active and inactive participants 2021-01-01 712
2020: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2020 401k membership
Total participants, beginning-of-year 2020-01-01 986
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 871
Number of retired or separated participants receiving benefits 2020-01-01 1
Total of all active and inactive participants 2020-01-01 872
2019: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,021
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 961
Number of retired or separated participants receiving benefits 2019-01-01 2
Total of all active and inactive participants 2019-01-01 963
2018: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2018 401k membership
Total participants, beginning-of-year 2018-01-01 955
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 1,037
Total of all active and inactive participants 2018-01-01 1,037
2017: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2017 401k membership
Total participants, beginning-of-year 2017-01-01 952
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 930
Total of all active and inactive participants 2017-01-01 930
2016: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,045
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 939
Total of all active and inactive participants 2016-01-01 939
2015: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2015 401k membership
Total participants, beginning-of-year 2015-01-01 961
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,045
Total of all active and inactive participants 2015-01-01 1,045
2014: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,045
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,028
Total of all active and inactive participants 2014-01-01 1,028
2013: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2013 401k membership
Total participants, beginning-of-year 2013-01-01 957
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,045
Total of all active and inactive participants 2013-01-01 1,045
2012: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,090
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 957
Total of all active and inactive participants 2012-01-01 957
2011: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2011 401k membership
Total participants, beginning-of-year 2011-01-01 999
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,090
Total of all active and inactive participants 2011-01-01 1,090
2010: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2010 401k membership
Total participants, beginning-of-year 2010-01-01 853
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 875
Total of all active and inactive participants 2010-01-01 875
2009: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2009 401k membership
Total participants, beginning-of-year 2009-01-01 411
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 416
Total of all active and inactive participants 2009-01-01 416

Measure	Date	Value
2022: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2022 401k membership
Total participants, beginning-of-year	2022-01-01	712
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	738
Total of all active and inactive participants	2022-01-01	738
2021: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2021 401k membership
Total participants, beginning-of-year	2021-01-01	874
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	712
Total of all active and inactive participants	2021-01-01	712
2020: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2020 401k membership
Total participants, beginning-of-year	2020-01-01	986
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	871
Number of retired or separated participants receiving benefits	2020-01-01	1
Total of all active and inactive participants	2020-01-01	872
2019: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,021
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	961
Number of retired or separated participants receiving benefits	2019-01-01	2
Total of all active and inactive participants	2019-01-01	963
2018: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2018 401k membership
Total participants, beginning-of-year	2018-01-01	955
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,037
Total of all active and inactive participants	2018-01-01	1,037
2017: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2017 401k membership
Total participants, beginning-of-year	2017-01-01	952
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	930
Total of all active and inactive participants	2017-01-01	930
2016: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,045
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	939
Total of all active and inactive participants	2016-01-01	939
2015: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2015 401k membership
Total participants, beginning-of-year	2015-01-01	961
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,045
Total of all active and inactive participants	2015-01-01	1,045
2014: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,045
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,028
Total of all active and inactive participants	2014-01-01	1,028
2013: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2013 401k membership
Total participants, beginning-of-year	2013-01-01	957
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,045
Total of all active and inactive participants	2013-01-01	1,045
2012: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,090
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	957
Total of all active and inactive participants	2012-01-01	957
2011: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2011 401k membership
Total participants, beginning-of-year	2011-01-01	999
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,090
Total of all active and inactive participants	2011-01-01	1,090
2010: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2010 401k membership
Total participants, beginning-of-year	2010-01-01	853
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	875
Total of all active and inactive participants	2010-01-01	875
2009: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2009 401k membership
Total participants, beginning-of-year	2009-01-01	411
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	416
Total of all active and inactive participants	2009-01-01	416

Form 5500 Responses for FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST

2022: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 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: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 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: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 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: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 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: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 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: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 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: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 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: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: FIRST ATLANTIC CORPORATION HEALTH PLAN TRUST 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

000563440

Policy instance

Insurance contract or identification number	000563440
Number of Individuals Covered	478
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $71,439
Total amount of fees paid to insurance company	USD $10,084
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $623,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,971
Amount paid for insurance broker fees	10084
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00565398

Policy instance

Insurance contract or identification number	00565398
Number of Individuals Covered	661
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $2,202
Total amount of fees paid to insurance company	USD $498
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $20,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,857
Amount paid for insurance broker fees	498
Insurance broker organization code?	3

ANTHEM HEALTH PLANS OF MAINE, INC. (National Association of Insurance Commissioners NAIC id number: 52618 )

Policy contract number

L00938

Policy instance

Insurance contract or identification number	L00938
Number of Individuals Covered	500
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $90,684
Total amount of fees paid to insurance company	USD $16,758
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,548,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $90,684
Amount paid for insurance broker fees	16758
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00565398

Policy instance

Insurance contract or identification number	00565398
Number of Individuals Covered	790
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $3,458
Total amount of fees paid to insurance company	USD $519
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $25,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,204
Amount paid for insurance broker fees	519
Insurance broker organization code?	3

ANTHEM HEALTH PLANS OF MAINE, INC. (National Association of Insurance Commissioners NAIC id number: 52618 )

Policy contract number

L00938

Policy instance

Insurance contract or identification number	L00938
Number of Individuals Covered	597
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $92,548
Total amount of fees paid to insurance company	USD $104,000
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,801,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $92,548
Amount paid for insurance broker fees	104000
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

000563440

Policy instance

Insurance contract or identification number	000563440
Number of Individuals Covered	558
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $101,038
Total amount of fees paid to insurance company	USD $6,271
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $575,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,816
Amount paid for insurance broker fees	6271
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00565398

Policy instance

Insurance contract or identification number	00565398
Number of Individuals Covered	941
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $4,881
Total amount of fees paid to insurance company	USD $332
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $36,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,537
Amount paid for insurance broker fees	332
Insurance broker organization code?	3

ANTHEM HEALTH PLANS OF MAINE, INC. (National Association of Insurance Commissioners NAIC id number: 52618 )

Policy contract number

L00938

Policy instance

Insurance contract or identification number	L00938
Number of Individuals Covered	708
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $17,549
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $964,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,549
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00565398

Policy instance

Insurance contract or identification number	00565398
Number of Individuals Covered	870
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,341
Total amount of fees paid to insurance company	USD $332
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $33,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,463
Amount paid for insurance broker fees	332
Insurance broker organization code?	3

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

Policy contract number

083970

Policy instance

Insurance contract or identification number	083970
Number of Individuals Covered	528
Insurance policy start date	2020-01-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $54,923
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,199,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,543
Insurance broker organization code?	3

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

Policy contract number

075243

Policy instance

Insurance contract or identification number	075243
Number of Individuals Covered	219
Insurance policy start date	2020-01-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $26,557
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,075,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,087
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

000563440

Policy instance

Insurance contract or identification number	000563440
Number of Individuals Covered	654
Insurance policy start date	2019-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $47,111
Total amount of fees paid to insurance company	USD $2,239
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $497,619
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,172
Insurance broker organization code?	3
Amount paid for insurance broker fees	2239

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

000563440

Policy instance

Insurance contract or identification number	000563440
Number of Individuals Covered	676
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $64,961
Total amount of fees paid to insurance company	USD $2,239
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $524,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,556
Insurance broker organization code?	3
Amount paid for insurance broker fees	2239

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

Policy contract number

021855

Policy instance

Insurance contract or identification number	021855
Number of Individuals Covered	233
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $47,030
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,734,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,030
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CL2533

Policy instance

Insurance contract or identification number	CL2533
Number of Individuals Covered	1041
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $2,263
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $33,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,263
Insurance broker organization code?	3

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

Policy contract number

075243

Policy instance

Insurance contract or identification number	075243
Number of Individuals Covered	151
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $24,671
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $906,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,671
Insurance broker organization code?	3

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

Policy contract number

000010050292

Policy instance

Insurance contract or identification number	000010050292
Number of Individuals Covered	53
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $2,949
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,949
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3341003

Policy instance

Insurance contract or identification number	3341003
Number of Individuals Covered	653
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $16,286
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $331,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,286
Insurance broker organization code?	3

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

Policy contract number

083970

Policy instance

Insurance contract or identification number	083970
Number of Individuals Covered	506
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $67,301
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,477,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67,301
Insurance broker organization code?	3

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

Policy contract number

000010050292

Policy instance

Insurance contract or identification number	000010050292
Number of Individuals Covered	49
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $2,439
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,439
Insurance broker organization code?	3

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

Policy contract number

083970

Policy instance

Insurance contract or identification number	083970
Number of Individuals Covered	425
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $51,918
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,037,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,918
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CL2533

Policy instance

Insurance contract or identification number	CL2533
Number of Individuals Covered	618
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $3,426
Total amount of fees paid to insurance company	USD $368
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,426
Amount paid for insurance broker fees	368
Additional information about fees paid to insurance broker	PURPOSE OF THESE FEES IS INCENTIVES, EDUCATION, COMMUNICATIONAND TRIN
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3341003

Policy instance

Insurance contract or identification number	3341003
Number of Individuals Covered	638
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $14,361
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $292,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,361
Insurance broker organization code?	3

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

Policy contract number

021857

Policy instance

Insurance contract or identification number	021857
Number of Individuals Covered	122
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $21,542
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $852,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,542
Insurance broker organization code?	3

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

Policy contract number

021855

Policy instance

Insurance contract or identification number	021855
Number of Individuals Covered	231
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $37,971
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,499,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,971
Insurance broker organization code?	3

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

Policy contract number

083970

Policy instance

Insurance contract or identification number	083970
Number of Individuals Covered	448
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $39,615
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,391,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,615
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021857

Policy instance

Insurance contract or identification number	021857
Number of Individuals Covered	129
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $42,568
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,496,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,568
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-040968

Policy instance

Insurance contract or identification number	010-040968
Number of Individuals Covered	1377
Insurance policy start date	2017-01-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $1,005
Total amount of fees paid to insurance company	USD $929
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $200,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,005
Amount paid for insurance broker fees	929
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021855

Policy instance

Insurance contract or identification number	021855
Number of Individuals Covered	225
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $39,609
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,393,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,609
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CL2533

Policy instance

Insurance contract or identification number	CL2533
Number of Individuals Covered	642
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,311
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $23,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,311
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

000010050292

Policy instance

Insurance contract or identification number	000010050292
Number of Individuals Covered	47
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,627
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,627
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-040968

Policy instance

Insurance contract or identification number	010-040968
Number of Individuals Covered	1559
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,772
Total amount of fees paid to insurance company	USD $6,916
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $322,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,772
Amount paid for insurance broker fees	6916
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

083970

Policy instance

Insurance contract or identification number	083970
Number of Individuals Covered	253
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $21,147
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $921,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,147
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

000010050292

Policy instance

Insurance contract or identification number	000010050292
Number of Individuals Covered	46
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,771
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,771
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CL2533

Policy instance

Insurance contract or identification number	CL2533
Number of Individuals Covered	690
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,698
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,698
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021855

Policy instance

Insurance contract or identification number	021855
Number of Individuals Covered	240
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $35,601
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,550,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,601
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021857

Policy instance

Insurance contract or identification number	021857
Number of Individuals Covered	337
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $46,693
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,889,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,693
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

000010050292

Policy instance

Insurance contract or identification number	000010050292
Number of Individuals Covered	40
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,600
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,600
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-040968

Policy instance

Insurance contract or identification number	010-040968
Number of Individuals Covered	1513
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,573
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $130,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,573
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021855

Policy instance

Insurance contract or identification number	021855
Number of Individuals Covered	188
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $34,484
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,428,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,484
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CL2533

Policy instance

Insurance contract or identification number	CL2533
Number of Individuals Covered	637
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,751
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $17,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,751
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

000010050292

Policy instance

Insurance contract or identification number	000010050292
Number of Individuals Covered	39
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,404
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,404
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05984380

Policy instance

Insurance contract or identification number	TM05984380
Number of Individuals Covered	1446
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,472
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $293,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,472
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021855

Policy instance

Insurance contract or identification number	021855
Number of Individuals Covered	151
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $24,708
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $961,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,708
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CL2533

Policy instance

Insurance contract or identification number	CL2533
Number of Individuals Covered	534
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,966
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $17,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,966
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CL2533

Policy instance

Insurance contract or identification number	CL2533
Number of Individuals Covered	562
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,048
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $20,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,048
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021857

Policy instance

Insurance contract or identification number	021857
Number of Individuals Covered	221
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $31,877
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $1,250,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,877
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05984380

Policy instance

Insurance contract or identification number	TM05984380
Number of Individuals Covered	1398
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,402
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $282,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,402
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021856

Policy instance

Insurance contract or identification number	021856
Number of Individuals Covered	98
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $24,179
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $910,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,179
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021855

Policy instance

Insurance contract or identification number	021855
Number of Individuals Covered	153
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $20,978
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $828,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,978
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

000010050292

Policy instance

Insurance contract or identification number	000010050292
Number of Individuals Covered	38
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,263
Total amount of fees paid to insurance company	USD $177
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,263
Amount paid for insurance broker fees	177
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021855

Policy instance

Insurance contract or identification number	021855
Number of Individuals Covered	112
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $20,726
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $769,280
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

021857

Policy instance

Insurance contract or identification number	021857
Number of Individuals Covered	214
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $35,275
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $1,294,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CL2533

Policy instance

Insurance contract or identification number	CL2533
Number of Individuals Covered	0
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $1,975
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $18,961
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

000010050292

Policy instance

Insurance contract or identification number	000010050292
Number of Individuals Covered	37
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,182
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )

Policy contract number

MS3650

Policy instance

Insurance contract or identification number	MS3650
Number of Individuals Covered	4307
Insurance policy start date	2011-01-01
Insurance policy end date	2011-08-01
Total amount of commissions paid to insurance broker	USD $2,822
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $138,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

021856

Policy instance

Insurance contract or identification number	021856
Number of Individuals Covered	162
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $31,772
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $1,157,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

US391096

Policy instance

Insurance contract or identification number	US391096
Number of Individuals Covered	561
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $34,238
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $2,182,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,238
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CL2533

Policy instance

Insurance contract or identification number	CL2533
Number of Individuals Covered	625
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,027
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $18,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,027
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

000010050292

Policy instance

Insurance contract or identification number	000010050292
Number of Individuals Covered	37
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,298
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,298
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

ANTHEM HEALTH PLANS OF MAINE, INC. (National Association of Insurance Commissioners NAIC id number: 52618 )

Policy contract number

MS3650

Policy instance

Insurance contract or identification number	MS3650
Number of Individuals Covered	821
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $8,695
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $282,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,695
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021855

Policy instance

Insurance contract or identification number	021855
Number of Individuals Covered	113
Insurance policy start date	2010-08-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $10,086
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $328,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,086
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021856

Policy instance

Insurance contract or identification number	021856
Number of Individuals Covered	203
Insurance policy start date	2010-08-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $16,784
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $547,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,784
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

021857

Policy instance

Insurance contract or identification number	021857
Number of Individuals Covered	250
Insurance policy start date	2010-08-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $18,296
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $588,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,296
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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

Policy contract number

308573

Policy instance

Insurance contract or identification number	308573
Number of Individuals Covered	233
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $15,171
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,179,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,171
Insurance broker organization code?	3
Insurance broker name	ACADIA BENEFITS, INC.

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Company Name:	FIRST ATLANTIC CORPORATION
Employer identification number (EIN):	010407925
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1988-11-01
Company Identification Number:	1303133
Legal Registered Office Address:	4465 e. genesee st. Onondaga SYRACUSE United States of America (USA) 13214