401k Plan data: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN plan

ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN
Plan identification number	504

ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Temporary disability (accident and sickness)

401k Sponsoring company profile

ANN & HOPE, INC. has sponsored the creation of one or more 401k plans.

Company Name: ANN & HOPE, INC.

Employer identification number (EIN): 050272463

NAIC Classification: 452200

Additional information about ANN & HOPE, INC.

Jurisdiction of Incorporation: Secretary of State Rhode Island

Incorporation Date: 1954-08-26

Company Identification Number: 000001078

Legal Registered Office Address: 68 KENNEDY PLAZA, SUITE 3

PROVIDENCE
United States of America (USA)
02903

More information about ANN & HOPE, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
504 2019-01-01
504 2018-01-01
504 2017-01-01 SAMUEL CHASE SAMUEL CHASE 2018-10-15
504 2016-01-01 SAMUEL CHASE SAMUEL CHASE 2017-10-03
504 2015-01-01 SAMUEL CHASE SAMUEL CHASE 2016-10-14
504 2015-01-01 SAMUEL CHASE SAMUEL CHASE 2017-02-07
504 2014-01-01 SAMUEL CHASE SAMUEL CHASE 2015-09-18
504 2013-01-01 SAMUEL CHASE SAMUEL CHASE 2014-09-23
504 2012-01-01 SAMUEL CHASE SAMUEL CHASE 2013-10-01
504 2011-01-01 SAMUEL CHASE SAMUEL CHASE 2012-10-12
504 2010-01-01 SAMUEL CHASE SAMUEL CHASE 2011-07-22
504 2009-01-01 SAMUEL CHASE SAMUEL CHASE 2010-10-13

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
504	2019-01-01
504	2018-01-01
504	2017-01-01	SAMUEL CHASE	SAMUEL CHASE	2018-10-15
504	2016-01-01	SAMUEL CHASE	SAMUEL CHASE	2017-10-03
504	2015-01-01	SAMUEL CHASE	SAMUEL CHASE	2016-10-14
504	2015-01-01	SAMUEL CHASE	SAMUEL CHASE	2017-02-07
504	2014-01-01	SAMUEL CHASE	SAMUEL CHASE	2015-09-18
504	2013-01-01	SAMUEL CHASE	SAMUEL CHASE	2014-09-23
504	2012-01-01	SAMUEL CHASE	SAMUEL CHASE	2013-10-01
504	2011-01-01	SAMUEL CHASE	SAMUEL CHASE	2012-10-12
504	2010-01-01	SAMUEL CHASE	SAMUEL CHASE	2011-07-22
504	2009-01-01	SAMUEL CHASE	SAMUEL CHASE	2010-10-13

Plan Statistics for ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2019: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 149
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
Total of all active and inactive participants 2019-01-01 0
2018: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 158
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 149
Total of all active and inactive participants 2018-01-01 149
2017: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 178
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 158
Total of all active and inactive participants 2017-01-01 158
2016: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 180
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 178
Total of all active and inactive participants 2016-01-01 178
2015: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 170
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 180
Total of all active and inactive participants 2015-01-01 180
2014: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 180
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 170
Total of all active and inactive participants 2014-01-01 170
2013: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 178
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 180
Total of all active and inactive participants 2013-01-01 180
2012: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 187
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 177
Number of retired or separated participants receiving benefits 2012-01-01 1
Total of all active and inactive participants 2012-01-01 178
2011: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 179
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 186
Number of retired or separated participants receiving benefits 2011-01-01 1
Total of all active and inactive participants 2011-01-01 187
2010: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 192
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 175
Number of retired or separated participants receiving benefits 2010-01-01 4
Total of all active and inactive participants 2010-01-01 179
2009: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 205
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 188
Number of retired or separated participants receiving benefits 2009-01-01 4
Total of all active and inactive participants 2009-01-01 192

Measure	Date	Value
2019: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	149
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Total of all active and inactive participants	2019-01-01	0
2018: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	158
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	149
Total of all active and inactive participants	2018-01-01	149
2017: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	178
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	158
Total of all active and inactive participants	2017-01-01	158
2016: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	180
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	178
Total of all active and inactive participants	2016-01-01	178
2015: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	170
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	180
Total of all active and inactive participants	2015-01-01	180
2014: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	180
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	170
Total of all active and inactive participants	2014-01-01	170
2013: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	178
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	180
Total of all active and inactive participants	2013-01-01	180
2012: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	187
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	177
Number of retired or separated participants receiving benefits	2012-01-01	1
Total of all active and inactive participants	2012-01-01	178
2011: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	179
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	186
Number of retired or separated participants receiving benefits	2011-01-01	1
Total of all active and inactive participants	2011-01-01	187
2010: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	192
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	175
Number of retired or separated participants receiving benefits	2010-01-01	4
Total of all active and inactive participants	2010-01-01	179
2009: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	205
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	188
Number of retired or separated participants receiving benefits	2009-01-01	4
Total of all active and inactive participants	2009-01-01	192

Form 5500 Responses for ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN

2019: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	This submission is the final filing	Yes
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	Yes
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: ANN & HOPE, INC. EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

00511812

Policy instance

Insurance contract or identification number	00511812
Number of Individuals Covered	149
Insurance policy start date	2019-01-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $132
Total amount of fees paid to insurance company	USD $125
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $132
Amount paid for insurance broker fees	125
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ETB008078

Policy instance

Insurance contract or identification number	ETB008078
Number of Individuals Covered	30
Insurance policy start date	2018-02-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $151
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $151
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0914015

Policy instance

Insurance contract or identification number	0914015
Number of Individuals Covered	163
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $25,920
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $864,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	25920
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960_200

Policy instance

Insurance contract or identification number	5960_200
Number of Individuals Covered	118
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $2,302
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,302
Insurance broker organization code?	3

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960_1

Policy instance

Insurance contract or identification number	5960_1
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $567
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $567
Insurance broker organization code?	3

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960_1

Policy instance

Insurance contract or identification number	5960_1
Number of Individuals Covered	46
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $615
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $615
Insurance broker organization code?	3

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960_200

Policy instance

Insurance contract or identification number	5960_200
Number of Individuals Covered	115
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,271
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,271
Insurance broker organization code?	3

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

Policy contract number

37479000

Policy instance

Insurance contract or identification number	37479000
Number of Individuals Covered	24
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $3,580
Total amount of fees paid to insurance company	USD $1,546
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $182,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,580
Insurance broker organization code?	3
Amount paid for insurance broker fees	1546

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

38233000

Policy instance

Insurance contract or identification number	38233000
Number of Individuals Covered	137
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $23,960
Total amount of fees paid to insurance company	USD $7,547
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $835,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,960
Insurance broker organization code?	3
Amount paid for insurance broker fees	7547

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

Policy contract number

00511812

Policy instance

Insurance contract or identification number	00511812
Number of Individuals Covered	149
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $793
Total amount of fees paid to insurance company	USD $748
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $793
Amount paid for insurance broker fees	748
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ETB008078

Policy instance

Insurance contract or identification number	ETB008078
Number of Individuals Covered	30
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $151
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $151
Insurance broker organization code?	3

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960_1

Policy instance

Insurance contract or identification number	5960_1
Number of Individuals Covered	46
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $615
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $615
Insurance broker organization code?	3
Insurance broker name	USI NEW ENGLAND, INC.

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960_200

Policy instance

Insurance contract or identification number	5960_200
Number of Individuals Covered	115
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,271
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,271
Insurance broker organization code?	3
Insurance broker name	USI NEW ENGLAND, INC.

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

38233000

Policy instance

Insurance contract or identification number	38233000
Number of Individuals Covered	148
Insurance policy start date	2016-03-01
Insurance policy end date	2017-02-28
Total amount of commissions paid to insurance broker	USD $23,540
Total amount of fees paid to insurance company	USD $5,784
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $722,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,540
Insurance broker organization code?	3
Amount paid for insurance broker fees	5784
Additional information about fees paid to insurance broker	OTHER
Insurance broker name	USI INSURANCE SERVICES, LLC.

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

Policy contract number

37479000

Policy instance

Insurance contract or identification number	37479000
Number of Individuals Covered	30
Insurance policy start date	2016-03-01
Insurance policy end date	2017-02-28
Total amount of commissions paid to insurance broker	USD $3,360
Total amount of fees paid to insurance company	USD $905
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $149,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,360
Insurance broker organization code?	3
Amount paid for insurance broker fees	905
Insurance broker name	USI INSURANCE SERVICES, LLC.

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

Policy contract number

00511812

Policy instance

Insurance contract or identification number	00511812
Number of Individuals Covered	158
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $893
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $893
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC.

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

Policy contract number

G000AAER

Policy instance

Insurance contract or identification number	G000AAER
Number of Individuals Covered	180
Insurance policy start date	2015-04-01
Insurance policy end date	2015-05-01
Total amount of commissions paid to insurance broker	USD $91
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $91
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC.

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

Policy contract number

00511812

Policy instance

Insurance contract or identification number	00511812
Number of Individuals Covered	180
Insurance policy start date	2015-05-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,581
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $878
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC.

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

37479000

Policy instance

Insurance contract or identification number	37479000
Number of Individuals Covered	19
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $3,509
Total amount of fees paid to insurance company	USD $619
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,509
Insurance broker organization code?	3
Amount paid for insurance broker fees	619
Insurance broker name	USI INSURANCE SERVICES, LLC.

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

38233000

Policy instance

Insurance contract or identification number	38233000
Number of Individuals Covered	149
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $28,344
Total amount of fees paid to insurance company	USD $5,036
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $764,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,344
Insurance broker organization code?	3
Amount paid for insurance broker fees	5036
Insurance broker name	USI INSURANCE SERVICES, LLC.

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960_200

Policy instance

Insurance contract or identification number	5960_200
Number of Individuals Covered	106
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,035
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,035
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC.

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960_1

Policy instance

Insurance contract or identification number	5960_1
Number of Individuals Covered	55
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $830
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $830
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC.

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

Policy contract number

G000AAER

Policy instance

Insurance contract or identification number	G000AAER
Number of Individuals Covered	183
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $1,066
Total amount of fees paid to insurance company	USD $472
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,066
Amount paid for insurance broker fees	472
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC.

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

Policy contract number

G000AAER

Policy instance

Insurance contract or identification number	G000AAER
Number of Individuals Covered	170
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $1,006
Total amount of fees paid to insurance company	USD $405
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 $10,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $835
Amount paid for insurance broker fees	405
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES OF RI, INC.

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960-1

Policy instance

Insurance contract or identification number	5960-1
Number of Individuals Covered	86
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,108
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,108
Insurance broker organization code?	3
Insurance broker name	USI NEW ENGLAND

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960-200

Policy instance

Insurance contract or identification number	5960-200
Number of Individuals Covered	90
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,789
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,789
Insurance broker organization code?	3
Insurance broker name	USI NEW ENGLAND

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

38233000

Policy instance

Insurance contract or identification number	38233000
Number of Individuals Covered	163
Insurance policy start date	2014-01-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $2,950
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 $152,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,950
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

37479000

Policy instance

Insurance contract or identification number	37479000
Number of Individuals Covered	20
Insurance policy start date	2014-01-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $360
Total amount of fees paid to insurance company	USD $1,578
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 $18,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $360
Amount paid for insurance broker fees	1578
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

37479000

Policy instance

Insurance contract or identification number	37479000
Number of Individuals Covered	10
Insurance policy start date	2013-03-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,679
Total amount of fees paid to insurance company	USD $888
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 $94,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,679
Amount paid for insurance broker fees	888
Additional information about fees paid to insurance broker	OTHER BROKER COMMISSSION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

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

Policy contract number

G000AAER

Policy instance

Insurance contract or identification number	G000AAER
Number of Individuals Covered	180
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $999
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 $9,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $999
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES OF RI, INC.

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960-1

Policy instance

Insurance contract or identification number	5960-1
Number of Individuals Covered	77
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,091
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,091
Insurance broker organization code?	3
Insurance broker name	USI NEW ENGLAND

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

38233000

Policy instance

Insurance contract or identification number	38233000
Number of Individuals Covered	94
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $23,310
Total amount of fees paid to insurance company	USD $7,793
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 $847,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,591
Insurance broker organization code?	3
Amount paid for insurance broker fees	7793
Additional information about fees paid to insurance broker	OTHER BROKER COMPENSATION
Insurance broker name	USI INSURANCE SERVICES, LLC.

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

37479000

Policy instance

Insurance contract or identification number	37479000
Number of Individuals Covered	10
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $2,568
Total amount of fees paid to insurance company	USD $1,028
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 $87,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,247
Insurance broker organization code?	3
Amount paid for insurance broker fees	1028
Additional information about fees paid to insurance broker	OTHER BROKER COMPENSATION
Insurance broker name	USI INSURANCE SERVICES, LLC.

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960-200

Policy instance

Insurance contract or identification number	5960-200
Number of Individuals Covered	94
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,801
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,801
Insurance broker organization code?	3
Insurance broker name	USI NEW ENGLAND

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

38233000

Policy instance

Insurance contract or identification number	38233000
Number of Individuals Covered	94
Insurance policy start date	2013-03-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $22,914
Total amount of fees paid to insurance company	USD $7,780
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 $759,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,914
Amount paid for insurance broker fees	7780
Additional information about fees paid to insurance broker	OTHER BROKER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

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

Policy contract number

G000AAER

Policy instance

Insurance contract or identification number	G000AAER
Number of Individuals Covered	177
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $995
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 $9,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $995
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES OF RI, INC.

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960-1

Policy instance

Insurance contract or identification number	5960-1
Number of Individuals Covered	92
Insurance policy start date	2012-01-01
Insurance policy end date	2002-12-31
Total amount of commissions paid to insurance broker	USD $1,400
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,400
Insurance broker organization code?	3
Insurance broker name	USI NEW ENGLAND INC

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

38233000

Policy instance

Insurance contract or identification number	38233000
Number of Individuals Covered	95
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $27,878
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 $802,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,575
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES OF RI, INC.

TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )

Policy contract number

37479000

Policy instance

Insurance contract or identification number	37479000
Number of Individuals Covered	11
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $3,284
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 $39,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,583
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES OF RI, INC.

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960-200

Policy instance

Insurance contract or identification number	5960-200
Number of Individuals Covered	89
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,392
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,392
Insurance broker organization code?	3
Insurance broker name	USI NEW ENGLAND INC

DELTA DENTAL OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

5960-1

Policy instance

Insurance contract or identification number	5960-1
Number of Individuals Covered	174
Insurance policy start date	2011-01-01
Insurance policy end date	2001-12-31
Total amount of commissions paid to insurance broker	USD $2,478
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

G000AAER

Policy instance

Insurance contract or identification number	G000AAER
Number of Individuals Covered	177
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $887
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 $8,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS AND BLUE SHIELD OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

101095

Policy instance

Insurance contract or identification number	101095
Number of Individuals Covered	103
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,847
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 $154,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

G000AAER

Policy instance

Insurance contract or identification number	G000AAER
Number of Individuals Covered	175
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $917
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 $9,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $917
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES OF RI, INC.

BLUE CROSS AND BLUE SHIELD OF RHODE ISLAND (National Association of Insurance Commissioners NAIC id number: 53473 )

Policy contract number

101095

Policy instance

Insurance contract or identification number	101095
Number of Individuals Covered	163
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $15,769
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 $992,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,769
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES OF RI, INC.

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Company Name:	ANN & HOPE, INC.
Employer identification number (EIN):	050272463
NAIC Classification:	452200

Jurisdiction of Incorporation:	Secretary of State Rhode Island
Incorporation Date:	1954-08-26
Company Identification Number:	000001078
Legal Registered Office Address:	68 KENNEDY PLAZA, SUITE 3 PROVIDENCE United States of America (USA) 02903