HENRY C. NEVINS HOME, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS
401k plan membership statisitcs for HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS
| Measure | Date | Value |
|---|
| 2022: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-08-01 | 116 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-08-01 | 120 |
| Number of retired or separated participants receiving benefits | 2022-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-08-01 | 0 |
| Total of all active and inactive participants | 2022-08-01 | 120 |
| Number of employers contributing to the scheme | 2022-08-01 | 0 |
| 2021: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-08-01 | 103 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-08-01 | 118 |
| Number of retired or separated participants receiving benefits | 2021-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-08-01 | 0 |
| Total of all active and inactive participants | 2021-08-01 | 118 |
| Number of employers contributing to the scheme | 2021-08-01 | 0 |
| 2019: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-08-01 | 130 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-08-01 | 96 |
| Number of retired or separated participants receiving benefits | 2019-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-08-01 | 0 |
| Total of all active and inactive participants | 2019-08-01 | 96 |
| Number of employers contributing to the scheme | 2019-08-01 | 0 |
| 2018: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-08-01 | 140 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-08-01 | 129 |
| Number of retired or separated participants receiving benefits | 2018-08-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2018-08-01 | 0 |
| Total of all active and inactive participants | 2018-08-01 | 132 |
| Number of employers contributing to the scheme | 2018-08-01 | 0 |
| 2017: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-08-01 | 144 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-08-01 | 145 |
| Number of retired or separated participants receiving benefits | 2017-08-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2017-08-01 | 0 |
| Total of all active and inactive participants | 2017-08-01 | 146 |
| Number of employers contributing to the scheme | 2017-08-01 | 0 |
| 2016: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-08-01 | 137 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-08-01 | 144 |
| Number of retired or separated participants receiving benefits | 2016-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-08-01 | 0 |
| Total of all active and inactive participants | 2016-08-01 | 144 |
| 2015: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-08-01 | 139 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-08-01 | 136 |
| Number of retired or separated participants receiving benefits | 2015-08-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2015-08-01 | 0 |
| Total of all active and inactive participants | 2015-08-01 | 137 |
| 2014: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-08-01 | 147 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-08-01 | 139 |
| Number of retired or separated participants receiving benefits | 2014-08-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2014-08-01 | 0 |
| Total of all active and inactive participants | 2014-08-01 | 140 |
| 2013: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-08-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-08-01 | 147 |
| Number of retired or separated participants receiving benefits | 2013-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-08-01 | 0 |
| Total of all active and inactive participants | 2013-08-01 | 147 |
| 2012: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-08-01 | 151 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-08-01 | 112 |
| Number of retired or separated participants receiving benefits | 2012-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-08-01 | 0 |
| Total of all active and inactive participants | 2012-08-01 | 112 |
| 2011: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-08-01 | 153 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-08-01 | 151 |
| Number of retired or separated participants receiving benefits | 2011-08-01 | 0 |
| Total of all active and inactive participants | 2011-08-01 | 151 |
| 2010: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-08-01 | 152 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-08-01 | 149 |
| Number of retired or separated participants receiving benefits | 2010-08-01 | 4 |
| Total of all active and inactive participants | 2010-08-01 | 153 |
| 2009: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-08-01 | 161 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-08-01 | 152 |
| Number of retired or separated participants receiving benefits | 2009-08-01 | 0 |
| Total of all active and inactive participants | 2009-08-01 | 152 |
| 2008: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-08-01 | 152 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-08-01 | 161 |
| Number of retired or separated participants receiving benefits | 2008-08-01 | 0 |
| Total of all active and inactive participants | 2008-08-01 | 161 |
| 2004: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2004 401k membership |
|---|
| Total participants, beginning-of-year | 2004-08-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2004-08-01 | 137 |
| Number of retired or separated participants receiving benefits | 2004-08-01 | 0 |
| Total of all active and inactive participants | 2004-08-01 | 137 |
| 2022: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2022 form 5500 responses |
|---|
| 2022-08-01 | Type of plan entity | Single employer plan |
| 2022-08-01 | Plan funding arrangement – Insurance | Yes |
| 2022-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2021 form 5500 responses |
|---|
| 2021-08-01 | Type of plan entity | Single employer plan |
| 2021-08-01 | Plan funding arrangement – Insurance | Yes |
| 2021-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2019 form 5500 responses |
|---|
| 2019-08-01 | Type of plan entity | Single employer plan |
| 2019-08-01 | Plan funding arrangement – Insurance | Yes |
| 2019-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2018 form 5500 responses |
|---|
| 2018-08-01 | Type of plan entity | Single employer plan |
| 2018-08-01 | Plan funding arrangement – Insurance | Yes |
| 2018-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2017 form 5500 responses |
|---|
| 2017-08-01 | Type of plan entity | Single employer plan |
| 2017-08-01 | Plan funding arrangement – Insurance | Yes |
| 2017-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2016 form 5500 responses |
|---|
| 2016-08-01 | Type of plan entity | Single employer plan |
| 2016-08-01 | Submission has been amended | No |
| 2016-08-01 | This submission is the final filing | No |
| 2016-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-08-01 | Plan is a collectively bargained plan | No |
| 2016-08-01 | Plan funding arrangement – Insurance | Yes |
| 2016-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2015 form 5500 responses |
|---|
| 2015-08-01 | Type of plan entity | Single employer plan |
| 2015-08-01 | Submission has been amended | No |
| 2015-08-01 | This submission is the final filing | No |
| 2015-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-08-01 | Plan is a collectively bargained plan | No |
| 2015-08-01 | Plan funding arrangement – Insurance | Yes |
| 2015-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2014 form 5500 responses |
|---|
| 2014-08-01 | Type of plan entity | Single employer plan |
| 2014-08-01 | Submission has been amended | No |
| 2014-08-01 | This submission is the final filing | No |
| 2014-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-08-01 | Plan is a collectively bargained plan | No |
| 2014-08-01 | Plan funding arrangement – Insurance | Yes |
| 2014-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2013 form 5500 responses |
|---|
| 2013-08-01 | Type of plan entity | Single employer plan |
| 2013-08-01 | Submission has been amended | No |
| 2013-08-01 | This submission is the final filing | No |
| 2013-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-08-01 | Plan is a collectively bargained plan | No |
| 2013-08-01 | Plan funding arrangement – Insurance | Yes |
| 2013-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2012 form 5500 responses |
|---|
| 2012-08-01 | Type of plan entity | Single employer plan |
| 2012-08-01 | Submission has been amended | No |
| 2012-08-01 | This submission is the final filing | No |
| 2012-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-08-01 | Plan is a collectively bargained plan | No |
| 2012-08-01 | Plan funding arrangement – Insurance | Yes |
| 2012-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2011 form 5500 responses |
|---|
| 2011-08-01 | Type of plan entity | Single employer plan |
| 2011-08-01 | Submission has been amended | Yes |
| 2011-08-01 | This submission is the final filing | No |
| 2011-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-08-01 | Plan is a collectively bargained plan | No |
| 2011-08-01 | Plan funding arrangement – Insurance | Yes |
| 2011-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2010 form 5500 responses |
|---|
| 2010-08-01 | Type of plan entity | Single employer plan |
| 2010-08-01 | Submission has been amended | No |
| 2010-08-01 | This submission is the final filing | No |
| 2010-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-08-01 | Plan is a collectively bargained plan | No |
| 2010-08-01 | Plan funding arrangement – Insurance | Yes |
| 2010-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2009 form 5500 responses |
|---|
| 2009-08-01 | Type of plan entity | Single employer plan |
| 2009-08-01 | Submission has been amended | No |
| 2009-08-01 | This submission is the final filing | No |
| 2009-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-08-01 | Plan is a collectively bargained plan | No |
| 2009-08-01 | Plan funding arrangement – Insurance | Yes |
| 2009-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2008 form 5500 responses |
|---|
| 2008-08-01 | Type of plan entity | Single employer plan |
| 2008-08-01 | Submission has been amended | No |
| 2008-08-01 | This submission is the final filing | No |
| 2008-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-08-01 | Plan is a collectively bargained plan | No |
| 2008-08-01 | Plan funding arrangement – Insurance | Yes |
| 2008-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2004: HENRY C. NEVINS HOME, INC. HEALTH AND WELFARE BENEFITS 2004 form 5500 responses |
|---|
| 2004-08-01 | Type of plan entity | Single employer plan |
| 2004-08-01 | First time form 5500 has been submitted | Yes |
| 2004-08-01 | Submission has been amended | No |
| 2004-08-01 | This submission is the final filing | No |
| 2004-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2004-08-01 | Plan is a collectively bargained plan | No |
| 2004-08-01 | Plan funding arrangement – Insurance | Yes |
| 2004-08-01 | Plan benefit arrangement – Insurance | Yes |
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956676 |
| Policy instance | 3 |
| Insurance contract or identification number | 4956676 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2022-08-01 | | Insurance policy end date | 2023-07-31 | | Total amount of commissions paid to insurance broker | USD $2,750 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,058 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,750 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 237119 |
| Policy instance | 1 |
| Insurance contract or identification number | 237119 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2022-08-01 | | Insurance policy end date | 2023-07-31 | | Total amount of commissions paid to insurance broker | USD $1,968 | | Total amount of fees paid to insurance company | USD $3 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $25,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,968 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OVERRIDE |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30050007 |
| Policy instance | 2 |
| Insurance contract or identification number | 30050007 | | Number of Individuals Covered | 44 | | Insurance policy start date | 2022-08-01 | | Insurance policy end date | 2023-07-31 | | Total amount of commissions paid to insurance broker | USD $468 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,703 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $468 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 84343 |
| Policy instance | 4 |
| Insurance contract or identification number | 84343 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2022-08-01 | | Insurance policy end date | 2023-07-31 | | Total amount of commissions paid to insurance broker | USD $24,458 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $991,009 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $24,458 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 84343 |
| Policy instance | 4 |
| Insurance contract or identification number | 84343 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $24,335 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $830,509 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,335 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 237119 |
| Policy instance | 1 |
| Insurance contract or identification number | 237119 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $2,524 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $28,908 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,524 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956676 |
| Policy instance | 3 |
| Insurance contract or identification number | 4956676 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $2,660 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $52,506 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,660 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30050007 |
| Policy instance | 2 |
| Insurance contract or identification number | 30050007 | | Number of Individuals Covered | 42 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $496 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,947 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $496 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956676 |
| Policy instance | 3 |
| Insurance contract or identification number | 4956676 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $2,643 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,278 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,643 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30050007 |
| Policy instance | 2 |
| Insurance contract or identification number | 30050007 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $342 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,561 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $342 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 237119 |
| Policy instance | 1 |
| Insurance contract or identification number | 237119 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $4,403 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $66,013 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,403 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 84343 |
| Policy instance | 4 |
| Insurance contract or identification number | 84343 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $8,016 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $944,905 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,016 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 84343 |
| Policy instance | 4 |
| Insurance contract or identification number | 84343 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $19,919 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,006,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $19,919 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30050007 |
| Policy instance | 2 |
| Insurance contract or identification number | 30050007 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $476 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,756 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $476 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 237119 |
| Policy instance | 1 |
| Insurance contract or identification number | 237119 | | Number of Individuals Covered | 129 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $5,068 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $73,537 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,068 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956676 |
| Policy instance | 3 |
| Insurance contract or identification number | 4956676 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $2,923 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $66,860 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,923 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956676 |
| Policy instance | 3 |
| Insurance contract or identification number | 4956676 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $3,528 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $79,181 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,528 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30050007 |
| Policy instance | 2 |
| Insurance contract or identification number | 30050007 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $396 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,288 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $396 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 84343 |
| Policy instance | 4 |
| Insurance contract or identification number | 84343 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $21,836 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,057,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $21,836 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 237119 |
| Policy instance | 1 |
| Insurance contract or identification number | 237119 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $5,084 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $77,084 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,084 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 237119 |
| Policy instance | 3 |
| Insurance contract or identification number | 237119 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-07-31 | | Total amount of commissions paid to insurance broker | USD $5,045 | | Total amount of fees paid to insurance company | USD $148 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $74,614 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,045 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 148 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | UNITED BENEFITS ADVISORS, INC. |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956676 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956676 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-07-31 | | Total amount of commissions paid to insurance broker | USD $3,752 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $70,456 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,752 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 297250000 |
| Policy instance | 1 |
| Insurance contract or identification number | 297250000 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-07-31 | | Total amount of commissions paid to insurance broker | USD $23,812 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $917,877 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $23,812 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956676 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956676 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $3,446 | | Total amount of fees paid to insurance company | USD $702 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $62,331 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,446 | | Amount paid for insurance broker fees | 702 | | Additional information about fees paid to insurance broker | BONUS PRESISTENCY COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 237119 |
| Policy instance | 3 |
| Insurance contract or identification number | 237119 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $5,007 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $74,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,007 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 29725/84343 |
| Policy instance | 1 |
| Insurance contract or identification number | 29725/84343 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $21,095 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $822,101 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $21,095 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956676 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956676 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $3,449 | | Total amount of fees paid to insurance company | USD $672 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $62,761 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,449 | | Amount paid for insurance broker fees | 672 | | Additional information about fees paid to insurance broker | BONUS PRESISTENCY COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | H64935 |
| Policy instance | 3 |
| Insurance contract or identification number | H64935 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $4,198 | | Total amount of fees paid to insurance company | USD $295 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $73,295 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,198 | | Amount paid for insurance broker fees | 295 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 29725/84343 |
| Policy instance | 1 |
| Insurance contract or identification number | 29725/84343 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $23,366 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $910,838 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $22,278 | | Insurance broker organization code? | 3 | | Insurance broker name | BUSINESS BENEFITS INSURANCE, INC. |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 029725 |
| Policy instance | 1 |
| Insurance contract or identification number | 029725 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $24,999 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $859,234 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $24,999 | | Insurance broker organization code? | 3 | | Insurance broker name | BUSINESS BENEFITS INSURANCE, INC. |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | H64935 |
| Policy instance | 3 |
| Insurance contract or identification number | H64935 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $4,491 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $87,194 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,491 | | Insurance broker organization code? | 3 | | Insurance broker name | BUSINESS BENEFITS INSURANCE, INC. |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956676 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956676 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $3,817 | | Total amount of fees paid to insurance company | USD $2,421 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $70,700 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,382 | | Amount paid for insurance broker fees | 2421 | | Additional information about fees paid to insurance broker | BONUS AND PERSISTENCY COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | H64935 |
| Policy instance | 3 |
| Insurance contract or identification number | H64935 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $4,250 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $80,055 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956676 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956676 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $28,009 | | Total amount of fees paid to insurance company | USD $3,241 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $955,359 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ALTUS DENTAL INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 52632 ) |
| Policy contract number | 77790001 |
| Policy instance | 1 |
| Insurance contract or identification number | 77790001 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $2,424 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $35,412 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | H64935 |
| Policy instance | 3 |
| Insurance contract or identification number | H64935 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $3,938 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $70,276 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 4956676 |
| Policy instance | 2 |
| Insurance contract or identification number | 4956676 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $22,599 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $803,382 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ALTUS DENTAL INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 52632 ) |
| Policy contract number | 77790001 |
| Policy instance | 1 |
| Insurance contract or identification number | 77790001 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $3,593 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $52,313 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 21524 |
| Policy instance | 4 |
| Insurance contract or identification number | 21524 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2009-07-01 | | Insurance policy end date | 2009-07-31 | | Total amount of commissions paid to insurance broker | USD $671 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,381 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010028585 |
| Policy instance | 5 |
| Insurance contract or identification number | 010028585 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2007-10-01 | | Insurance policy end date | 2008-09-30 | | Total amount of commissions paid to insurance broker | USD $2,688 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $53,363 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 21524 |
| Policy instance | 2 |
| Insurance contract or identification number | 21524 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2008-07-01 | | Insurance policy end date | 2009-06-30 | | Total amount of commissions paid to insurance broker | USD $4,595 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEALTH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $79,058 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ALTUS DENTAL INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 52632 ) |
| Policy contract number | 7779_1 |
| Policy instance | 1 |
| Insurance contract or identification number | 7779_1 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2008-10-01 | | Insurance policy end date | 2008-12-31 | | Total amount of commissions paid to insurance broker | USD $890 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $12,885 | | 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 | 067797 |
| Policy instance | 3 |
| Insurance contract or identification number | 067797 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2008-08-01 | | Insurance policy end date | 2009-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $19,683 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $719,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 21524 |
| Policy instance | 2 |
| Insurance contract or identification number | 21524 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2007-07-01 | | Insurance policy end date | 2008-06-30 | | Total amount of commissions paid to insurance broker | USD $6,265 | | Total amount of fees paid to insurance company | USD $1,474 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $72,410 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010208585 |
| Policy instance | 3 |
| Insurance contract or identification number | 010208585 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2005-10-01 | | Insurance policy end date | 2006-09-30 | | Total amount of commissions paid to insurance broker | USD $2,576 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $50,467 | | 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 | 067797 |
| Policy instance | 1 |
| Insurance contract or identification number | 067797 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2006-08-01 | | Insurance policy end date | 2007-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $17,402 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $627,955 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 21524 |
| Policy instance | 2 |
| Insurance contract or identification number | 21524 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2006-07-01 | | Insurance policy end date | 2007-06-30 | | Total amount of commissions paid to insurance broker | USD $6,449 | | Total amount of fees paid to insurance company | USD $1,453 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $76,348 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010208585 |
| Policy instance | 1 |
| Insurance contract or identification number | 010208585 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2005-10-01 | | Insurance policy end date | 2006-09-30 | | Total amount of commissions paid to insurance broker | USD $2,576 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $50,467 | | 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 | 067797 |
| Policy instance | 3 |
| Insurance contract or identification number | 067797 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2006-08-01 | | Insurance policy end date | 2007-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $17,402 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $627,955 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 ) |
| Policy contract number | G50511 |
| Policy instance | 1 |
| Insurance contract or identification number | G50511 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2005-07-01 | | Insurance policy end date | 2006-06-30 | | Total amount of commissions paid to insurance broker | USD $489 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,262 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 ) |
| Policy contract number | G15410 |
| Policy instance | 2 |
| Insurance contract or identification number | G15410 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2005-07-01 | | Insurance policy end date | 2006-06-30 | | Total amount of commissions paid to insurance broker | USD $1,966 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEALTH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $28,092 | | 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 | 067797 |
| Policy instance | 3 |
| Insurance contract or identification number | 067797 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2005-08-01 | | Insurance policy end date | 2006-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $17,688 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $536,318 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 ) |
| Policy contract number | G15410 |
| Policy instance | 2 |
| Insurance contract or identification number | G15410 | | Insurance policy start date | 2004-07-01 | | Insurance policy end date | 2005-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 067797 |
| Policy instance | 1 |
| Insurance contract or identification number | 067797 | | Number of Individuals Covered | 148 | | Insurance policy start date | 2004-08-01 | | Insurance policy end date | 2005-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $18,019 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $636,010 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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