401k Plan data: HANNOUSH JEWELERS BENEFITS PLAN plan

HANNOUSH JEWELERS BENEFITS PLAN 401k Plan overview

Plan Name	HANNOUSH JEWELERS BENEFITS PLAN
Plan identification number	501

HANNOUSH JEWELERS BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

HANNOUSH JEWELERS, INC. has sponsored the creation of one or more 401k plans.

Company Name: HANNOUSH JEWELERS, INC.

Employer identification number (EIN): 042706327

NAIC Classification: 448310
NAIC Description: Jewelry Stores

Additional information about HANNOUSH JEWELERS, INC.

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1988-10-24

Company Identification Number: 1300964

Legal Registered Office Address: 112 WOLF ROAD
Albany
ALBANY
United States of America (USA)
12205

More information about HANNOUSH JEWELERS, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HANNOUSH JEWELERS BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2018-04-01 LISA BAILLARGEON 2019-10-02
501 2018-04-01 LISA BAILLARGEON 2021-02-05
501 2017-04-01
501 2016-04-01
501 2015-04-01 NORMAN A HANNOUSH
501 2014-04-01 NORMAN A HANNOUSH
501 2013-04-01
501 2012-04-01 NORMAN HANNOUSH
501 2011-04-01 NORMAN HANNOUSH
501 2005-04-01 NORMAN HANNOUSH
501 2003-04-01 NORMAN HANNOUSH
501 2001-04-01 NORMAN HANNOUSH

Plan Statistics for HANNOUSH JEWELERS BENEFITS PLAN

401k plan membership statisitcs for HANNOUSH JEWELERS BENEFITS PLAN

Measure Date Value
2018: HANNOUSH JEWELERS BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-04-01 174
Total number of active participants reported on line 7a of the Form 5500 2018-04-01 148
Number of retired or separated participants receiving benefits 2018-04-01 0
Number of other retired or separated participants entitled to future benefits 2018-04-01 0
Total of all active and inactive participants 2018-04-01 148
Number of employers contributing to the scheme 2018-04-01 0
2017: HANNOUSH JEWELERS BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-04-01 172
Total number of active participants reported on line 7a of the Form 5500 2017-04-01 172
Number of retired or separated participants receiving benefits 2017-04-01 0
Number of other retired or separated participants entitled to future benefits 2017-04-01 0
Total of all active and inactive participants 2017-04-01 172
2016: HANNOUSH JEWELERS BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-04-01 202
Total number of active participants reported on line 7a of the Form 5500 2016-04-01 206
Number of retired or separated participants receiving benefits 2016-04-01 0
Number of other retired or separated participants entitled to future benefits 2016-04-01 0
Total of all active and inactive participants 2016-04-01 206
2015: HANNOUSH JEWELERS BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-04-01 188
Total number of active participants reported on line 7a of the Form 5500 2015-04-01 202
Number of retired or separated participants receiving benefits 2015-04-01 0
Number of other retired or separated participants entitled to future benefits 2015-04-01 0
Total of all active and inactive participants 2015-04-01 202
2014: HANNOUSH JEWELERS BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-04-01 262
Total number of active participants reported on line 7a of the Form 5500 2014-04-01 188
Number of retired or separated participants receiving benefits 2014-04-01 0
Number of other retired or separated participants entitled to future benefits 2014-04-01 0
Total of all active and inactive participants 2014-04-01 188
2013: HANNOUSH JEWELERS BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-04-01 165
Total number of active participants reported on line 7a of the Form 5500 2013-04-01 262
Total of all active and inactive participants 2013-04-01 262
2012: HANNOUSH JEWELERS BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-04-01 147
Total number of active participants reported on line 7a of the Form 5500 2012-04-01 165
Total of all active and inactive participants 2012-04-01 165
2011: HANNOUSH JEWELERS BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-04-01 144
Total number of active participants reported on line 7a of the Form 5500 2011-04-01 147
Total of all active and inactive participants 2011-04-01 147
2005: HANNOUSH JEWELERS BENEFITS PLAN 2005 401k membership
Total participants, beginning-of-year 2005-04-01 242
Total number of active participants reported on line 7a of the Form 5500 2005-04-01 256
Total of all active and inactive participants 2005-04-01 256
2003: HANNOUSH JEWELERS BENEFITS PLAN 2003 401k membership
Total participants, beginning-of-year 2003-04-01 185
Total number of active participants reported on line 7a of the Form 5500 2003-04-01 236
Total of all active and inactive participants 2003-04-01 236
2001: HANNOUSH JEWELERS BENEFITS PLAN 2001 401k membership
Total participants, beginning-of-year 2001-04-01 174
Total number of active participants reported on line 7a of the Form 5500 2001-04-01 179
Total of all active and inactive participants 2001-04-01 179

Measure	Date	Value
2018: HANNOUSH JEWELERS BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-04-01	174
Total number of active participants reported on line 7a of the Form 5500	2018-04-01	148
Number of retired or separated participants receiving benefits	2018-04-01	0
Number of other retired or separated participants entitled to future benefits	2018-04-01	0
Total of all active and inactive participants	2018-04-01	148
Number of employers contributing to the scheme	2018-04-01	0
2017: HANNOUSH JEWELERS BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-04-01	172
Total number of active participants reported on line 7a of the Form 5500	2017-04-01	172
Number of retired or separated participants receiving benefits	2017-04-01	0
Number of other retired or separated participants entitled to future benefits	2017-04-01	0
Total of all active and inactive participants	2017-04-01	172
2016: HANNOUSH JEWELERS BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-04-01	202
Total number of active participants reported on line 7a of the Form 5500	2016-04-01	206
Number of retired or separated participants receiving benefits	2016-04-01	0
Number of other retired or separated participants entitled to future benefits	2016-04-01	0
Total of all active and inactive participants	2016-04-01	206
2015: HANNOUSH JEWELERS BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-04-01	188
Total number of active participants reported on line 7a of the Form 5500	2015-04-01	202
Number of retired or separated participants receiving benefits	2015-04-01	0
Number of other retired or separated participants entitled to future benefits	2015-04-01	0
Total of all active and inactive participants	2015-04-01	202
2014: HANNOUSH JEWELERS BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-04-01	262
Total number of active participants reported on line 7a of the Form 5500	2014-04-01	188
Number of retired or separated participants receiving benefits	2014-04-01	0
Number of other retired or separated participants entitled to future benefits	2014-04-01	0
Total of all active and inactive participants	2014-04-01	188
2013: HANNOUSH JEWELERS BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-04-01	165
Total number of active participants reported on line 7a of the Form 5500	2013-04-01	262
Total of all active and inactive participants	2013-04-01	262
2012: HANNOUSH JEWELERS BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-04-01	147
Total number of active participants reported on line 7a of the Form 5500	2012-04-01	165
Total of all active and inactive participants	2012-04-01	165
2011: HANNOUSH JEWELERS BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-04-01	144
Total number of active participants reported on line 7a of the Form 5500	2011-04-01	147
Total of all active and inactive participants	2011-04-01	147
2005: HANNOUSH JEWELERS BENEFITS PLAN 2005 401k membership
Total participants, beginning-of-year	2005-04-01	242
Total number of active participants reported on line 7a of the Form 5500	2005-04-01	256
Total of all active and inactive participants	2005-04-01	256
2003: HANNOUSH JEWELERS BENEFITS PLAN 2003 401k membership
Total participants, beginning-of-year	2003-04-01	185
Total number of active participants reported on line 7a of the Form 5500	2003-04-01	236
Total of all active and inactive participants	2003-04-01	236
2001: HANNOUSH JEWELERS BENEFITS PLAN 2001 401k membership
Total participants, beginning-of-year	2001-04-01	174
Total number of active participants reported on line 7a of the Form 5500	2001-04-01	179
Total of all active and inactive participants	2001-04-01	179

Form 5500 Responses for HANNOUSH JEWELERS BENEFITS PLAN

2018: HANNOUSH JEWELERS BENEFITS PLAN 2018 form 5500 responses
2018-04-01	Type of plan entity	Single employer plan
2018-04-01	Submission has been amended	Yes
2018-04-01	Plan funding arrangement – Insurance	Yes
2018-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-04-01	Plan benefit arrangement – Insurance	Yes
2018-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: HANNOUSH JEWELERS BENEFITS PLAN 2017 form 5500 responses
2017-04-01	Type of plan entity	Single employer plan
2017-04-01	Plan funding arrangement – Insurance	Yes
2017-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-04-01	Plan benefit arrangement – Insurance	Yes
2017-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: HANNOUSH JEWELERS BENEFITS PLAN 2016 form 5500 responses
2016-04-01	Type of plan entity	Single employer plan
2016-04-01	Submission has been amended	No
2016-04-01	This submission is the final filing	No
2016-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-04-01	Plan is a collectively bargained plan	No
2016-04-01	Plan funding arrangement – Insurance	Yes
2016-04-01	Plan benefit arrangement – Insurance	Yes
2015: HANNOUSH JEWELERS BENEFITS PLAN 2015 form 5500 responses
2015-04-01	Type of plan entity	Single employer plan
2015-04-01	Submission has been amended	No
2015-04-01	This submission is the final filing	No
2015-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-04-01	Plan is a collectively bargained plan	No
2015-04-01	Plan funding arrangement – Insurance	Yes
2015-04-01	Plan benefit arrangement – Insurance	Yes
2014: HANNOUSH JEWELERS BENEFITS PLAN 2014 form 5500 responses
2014-04-01	Type of plan entity	Single employer plan
2014-04-01	Submission has been amended	No
2014-04-01	This submission is the final filing	No
2014-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-04-01	Plan is a collectively bargained plan	No
2014-04-01	Plan funding arrangement – Insurance	Yes
2014-04-01	Plan benefit arrangement – Insurance	Yes
2013: HANNOUSH JEWELERS BENEFITS PLAN 2013 form 5500 responses
2013-04-01	Type of plan entity	Single employer plan
2013-04-01	Plan funding arrangement – Insurance	Yes
2013-04-01	Plan benefit arrangement – Insurance	Yes
2012: HANNOUSH JEWELERS BENEFITS PLAN 2012 form 5500 responses
2012-04-01	Type of plan entity	Single employer plan
2012-04-01	Plan funding arrangement – Insurance	Yes
2012-04-01	Plan benefit arrangement – Insurance	Yes
2011: HANNOUSH JEWELERS BENEFITS PLAN 2011 form 5500 responses
2011-04-01	Type of plan entity	Single employer plan
2011-04-01	Plan funding arrangement – Insurance	Yes
2011-04-01	Plan benefit arrangement – Insurance	Yes
2005: HANNOUSH JEWELERS BENEFITS PLAN 2005 form 5500 responses
2005-04-01	Type of plan entity	Single employer plan
2005-04-01	Plan funding arrangement – Insurance	Yes
2005-04-01	Plan benefit arrangement – Insurance	Yes
2003: HANNOUSH JEWELERS BENEFITS PLAN 2003 form 5500 responses
2003-04-01	Type of plan entity	Single employer plan
2003-04-01	Plan funding arrangement – Insurance	Yes
2003-04-01	Plan benefit arrangement – Insurance	Yes
2001: HANNOUSH JEWELERS BENEFITS PLAN 2001 form 5500 responses
2001-04-01	Type of plan entity	Single employer plan
2001-04-01	Plan funding arrangement – Insurance	Yes
2001-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

074497 ET AL

Policy instance

Insurance contract or identification number	074497 ET AL
Number of Individuals Covered	258
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $58,781
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 $1,816,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $58,781
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

756453

Policy instance

Insurance contract or identification number	756453
Number of Individuals Covered	115
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $4,423
Total amount of fees paid to insurance company	USD $620
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,423
Amount paid for insurance broker fees	620
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

10110271 ET AL

Policy instance

Insurance contract or identification number	10110271 ET AL
Number of Individuals Covered	94
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $295
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $295
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BBVR

Policy instance

Insurance contract or identification number	GLTD0BBVR
Number of Individuals Covered	24
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $1,391
Total amount of fees paid to insurance company	USD $410
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
Welfare Benefit Premiums Paid to Carrier	USD $13,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,391
Amount paid for insurance broker fees	410
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4958335

Policy instance

Insurance contract or identification number	4958335
Number of Individuals Covered	477
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $73,609
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $73,609
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	SMITH BROTHERS INSURANCE, LLC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AWDB

Policy instance

Insurance contract or identification number	GLUG0AWDB
Number of Individuals Covered	180
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $8,918
Total amount of fees paid to insurance company	USD $2,745
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
Welfare Benefit Premiums Paid to Carrier	USD $89,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,918
Amount paid for insurance broker fees	2745
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	SBI BENEFITS CONSULTANTS, LLC

TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )

Policy contract number

46697000

Policy instance

Insurance contract or identification number	46697000
Number of Individuals Covered	393
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $66,407
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 $2,232,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $66,407
Insurance broker organization code?	3
Insurance broker name	SMITH BROTHERS INSURANCE, LLC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AWDB

Policy instance

Insurance contract or identification number	GLUG0AWDB
Number of Individuals Covered	202
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $9,519
Total amount of fees paid to insurance company	USD $1,586
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 $95,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,519
Amount paid for insurance broker fees	1586
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	SMITH BROTHERS INSURANCE, LLC

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

Policy contract number

511427

Policy instance

Insurance contract or identification number	511427
Number of Individuals Covered	174
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $4,200
Total amount of fees paid to insurance company	USD $1,572
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 $146,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,200
Amount paid for insurance broker fees	1572
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	SMITH BROTHERS INSURANCE

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001703

Policy instance

Insurance contract or identification number	50001703
Number of Individuals Covered	188
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $23,204
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 $102,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,204
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	422
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $81,348
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	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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $81,348
Insurance broker organization code?	3
Insurance broker name	AHMAD A. ZEBIAN

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001703

Policy instance

Insurance contract or identification number	50001703
Number of Individuals Covered	262
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $7,369
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,369
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001703

Policy instance

Insurance contract or identification number	50001703
Number of Individuals Covered	97
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $6,306
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,306
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001703

Policy instance

Insurance contract or identification number	50001703
Number of Individuals Covered	262
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $7,787
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,787
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	AHMAD A. ZEBIAN

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001703

Policy instance

Insurance contract or identification number	50001703
Number of Individuals Covered	262
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $3,261
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $14,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,261
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	219
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $6,150
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,150
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	AHMAD A. ZEBIAN

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	207
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $64,710
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $64,710
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	AHMAD A. ZEBIAN

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001703

Policy instance

Insurance contract or identification number	50001703
Number of Individuals Covered	125
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $1,944
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,944
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	143
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $5,561
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,561
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	AHMAD A. ZEBIAN

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001703

Policy instance

Insurance contract or identification number	50001703
Number of Individuals Covered	125
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $4,096
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,096
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

5001703

Policy instance

Insurance contract or identification number	5001703
Number of Individuals Covered	125
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $4,426
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,426
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001703

Policy instance

Insurance contract or identification number	50001703
Number of Individuals Covered	68
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $4,074
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,074
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	INDIGO INSURANCE SERVICES

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	165
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $53,602
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,602
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	AHMAD A. ZEBIAN

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001703

Policy instance

Insurance contract or identification number	50001703
Number of Individuals Covered	71
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $3,730
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

5001703

Policy instance

Insurance contract or identification number	5001703
Number of Individuals Covered	123
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $3,864
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001703

Policy instance

Insurance contract or identification number	50001703
Number of Individuals Covered	123
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $3,081
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,406
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	147
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $5,649
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	145
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $47,943
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001703

Policy instance

Insurance contract or identification number	50001703
Number of Individuals Covered	123
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $1,658
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	83
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $4,524
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	83
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $3,586
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	83
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $1,931
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,654
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	144
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $5,233
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	118
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $39,162
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	74
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $3,757
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	67
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $2,720
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	67
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $4,896
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	67
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $6,369
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,843
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	154
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $5,199
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	72
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $4,731
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,926
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	136
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $39,876
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	163
Insurance policy start date	2008-04-01
Insurance policy end date	2009-03-31
Total amount of commissions paid to insurance broker	USD $3,504
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $14,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	51
Insurance policy start date	2008-04-01
Insurance policy end date	2009-03-31
Total amount of commissions paid to insurance broker	USD $5,422
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,698
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	124
Insurance policy start date	2008-04-01
Insurance policy end date	2009-03-31
Total amount of commissions paid to insurance broker	USD $40,794
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	18
Insurance policy start date	2008-04-01
Insurance policy end date	2009-03-31
Total amount of commissions paid to insurance broker	USD $4,817
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	7
Insurance policy start date	2008-04-01
Insurance policy end date	2009-03-31
Total amount of commissions paid to insurance broker	USD $1,292
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	165
Insurance policy start date	2008-04-01
Insurance policy end date	2009-03-31
Total amount of commissions paid to insurance broker	USD $6,252
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1014518

Policy instance

Insurance contract or identification number	1014518
Number of Individuals Covered	165
Insurance policy start date	2008-04-01
Insurance policy end date	2009-03-31
Total amount of commissions paid to insurance broker	USD $8,803
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,680
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	163
Insurance policy start date	2008-04-01
Insurance policy end date	2009-03-31
Total amount of commissions paid to insurance broker	USD $5,615
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00283728

Policy instance

Insurance contract or identification number	00283728
Number of Individuals Covered	247
Insurance policy start date	2007-04-01
Insurance policy end date	2008-03-31
Total amount of commissions paid to insurance broker	USD $17,206
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $333,251
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	169
Insurance policy start date	2007-04-01
Insurance policy end date	2008-03-31
Total amount of commissions paid to insurance broker	USD $72,110
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	23
Insurance policy start date	2007-04-01
Insurance policy end date	2008-03-31
Total amount of commissions paid to insurance broker	USD $6,696
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $171,082
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	16
Insurance policy start date	2006-04-01
Insurance policy end date	2007-03-31
Total amount of commissions paid to insurance broker	USD $6,760
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $167,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00283728

Policy instance

Insurance contract or identification number	00283728
Number of Individuals Covered	262
Insurance policy start date	2006-04-01
Insurance policy end date	2007-03-31
Total amount of commissions paid to insurance broker	USD $16,902
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $317,797
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	178
Insurance policy start date	2006-04-01
Insurance policy end date	2007-03-31
Total amount of commissions paid to insurance broker	USD $66,002
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	16
Insurance policy start date	2005-04-01
Insurance policy end date	2006-03-31
Total amount of commissions paid to insurance broker	USD $4,648
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00283728

Policy instance

Insurance contract or identification number	00283728
Number of Individuals Covered	256
Insurance policy start date	2005-04-01
Insurance policy end date	2006-03-31
Total amount of commissions paid to insurance broker	USD $16,911
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $314,470
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	192
Insurance policy start date	2005-04-01
Insurance policy end date	2006-03-31
Total amount of commissions paid to insurance broker	USD $66,597
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00283728

Policy instance

Insurance contract or identification number	00283728
Number of Individuals Covered	242
Insurance policy start date	2004-04-01
Insurance policy end date	2005-03-31
Total amount of commissions paid to insurance broker	USD $16,815
Total amount of fees paid to insurance company	USD $4,454
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $327,022
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	11
Insurance policy start date	2004-04-01
Insurance policy end date	2005-03-31
Total amount of commissions paid to insurance broker	USD $4,367
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	199
Insurance policy start date	2004-04-01
Insurance policy end date	2005-03-31
Total amount of commissions paid to insurance broker	USD $59,496
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	4
Insurance policy start date	2003-04-01
Insurance policy end date	2004-03-31
Total amount of commissions paid to insurance broker	USD $1,099
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	188
Insurance policy start date	2003-04-01
Insurance policy end date	2004-03-31
Total amount of commissions paid to insurance broker	USD $52,017
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00283728

Policy instance

Insurance contract or identification number	00283728
Number of Individuals Covered	236
Insurance policy start date	2003-04-01
Insurance policy end date	2004-03-31
Total amount of commissions paid to insurance broker	USD $16,337
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $290,528
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	12
Insurance policy start date	2003-04-01
Insurance policy end date	2004-03-31
Total amount of commissions paid to insurance broker	USD $3,420
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	5
Insurance policy start date	2002-04-01
Insurance policy end date	2003-03-31
Total amount of commissions paid to insurance broker	USD $1,149
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	172
Insurance policy start date	2002-04-01
Insurance policy end date	2003-03-31
Total amount of commissions paid to insurance broker	USD $41,341
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	8
Insurance policy start date	2002-04-01
Insurance policy end date	2003-03-31
Total amount of commissions paid to insurance broker	USD $4,288
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	169
Insurance policy start date	2001-04-01
Insurance policy end date	2002-03-31
Total amount of commissions paid to insurance broker	USD $37,728
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	5
Insurance policy start date	2001-04-01
Insurance policy end date	2002-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	5
Insurance policy start date	2001-04-01
Insurance policy end date	2002-03-31
Total amount of commissions paid to insurance broker	USD $820
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	7
Insurance policy start date	2000-04-01
Insurance policy end date	2001-03-31
Total amount of commissions paid to insurance broker	USD $214
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	5
Insurance policy start date	2000-04-01
Insurance policy end date	2001-03-31
Total amount of commissions paid to insurance broker	USD $632
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
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

4937977

Policy instance

Insurance contract or identification number	4937977
Number of Individuals Covered	162
Insurance policy start date	2000-04-01
Insurance policy end date	2001-03-31
Total amount of commissions paid to insurance broker	USD $25,939
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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The information published is supplied by third parties so we make no warranty on the accuracy, completeness etc. This information is provided "as-is". The information is subject to change as we obtain updates and corrections from the primary information sources.
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Company Name:	HANNOUSH JEWELERS, INC.
Employer identification number (EIN):	042706327
NAIC Classification:	448310
NAIC Description:	Jewelry Stores

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1988-10-24
Company Identification Number:	1300964
Legal Registered Office Address:	112 WOLF ROAD Albany ALBANY United States of America (USA) 12205

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2018-04-01	LISA BAILLARGEON	2019-10-02
501	2018-04-01	LISA BAILLARGEON	2021-02-05
501	2017-04-01
501	2016-04-01
501	2015-04-01	NORMAN A HANNOUSH
501	2014-04-01	NORMAN A HANNOUSH
501	2013-04-01
501	2012-04-01	NORMAN HANNOUSH
501	2011-04-01	NORMAN HANNOUSH
501	2005-04-01	NORMAN HANNOUSH
501	2003-04-01	NORMAN HANNOUSH
501	2001-04-01	NORMAN HANNOUSH