401k Plan data: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. plan

MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 401k Plan overview

Plan Name	MORRISVILLE AUXILIARY HOSPITAL PLAN INC.
Plan identification number	501

MORRISVILLE AUXILIARY HOSPITAL PLAN INC. Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover

401k Sponsoring company profile

MORRISVILLE AUX OF STATEUNIVCOLLEGE OF AGRI AND TECH AT MORRISVILLEINC has sponsored the creation of one or more 401k plans.

Company Name: MORRISVILLE AUX OF STATEUNIVCOLLEGE OF AGRI AND TECH AT MORRISVILLEINC

Employer identification number (EIN): 150560110

NAIC Classification: 611000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MORRISVILLE AUXILIARY HOSPITAL PLAN INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 SARAH MAZZA 2023-07-25 SARAH MAZZA 2023-07-25
501 2021-01-01 JENNIFER BOWDEN 2022-07-06 JENNIFER BOWDEN 2022-07-06
501 2020-01-01 JENNIFER BOWDEN 2021-07-21 JENNIFER BOWDEN 2021-07-21
501 2018-01-01
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 JENNIFER S. STOWELL
501 2011-01-01 JENNIFER S. STOWELL

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	SARAH MAZZA	2023-07-25	SARAH MAZZA	2023-07-25
501	2021-01-01	JENNIFER BOWDEN	2022-07-06	JENNIFER BOWDEN	2022-07-06
501	2020-01-01	JENNIFER BOWDEN	2021-07-21	JENNIFER BOWDEN	2021-07-21
501	2018-01-01
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	JENNIFER S. STOWELL
501	2011-01-01	JENNIFER S. STOWELL

Plan Statistics for MORRISVILLE AUXILIARY HOSPITAL PLAN INC.

401k plan membership statisitcs for MORRISVILLE AUXILIARY HOSPITAL PLAN INC.

Measure Date Value
2022: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2022 401k membership
Total participants, beginning-of-year 2022-01-01 88
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 70
Number of retired or separated participants receiving benefits 2022-01-01 1
Total of all active and inactive participants 2022-01-01 71
2021: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2021 401k membership
Total participants, beginning-of-year 2021-01-01 92
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 88
Total of all active and inactive participants 2021-01-01 88
2020: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2020 401k membership
Total participants, beginning-of-year 2020-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 91
Number of retired or separated participants receiving benefits 2020-01-01 1
Total of all active and inactive participants 2020-01-01 92
2018: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2018 401k membership
Total participants, beginning-of-year 2018-01-01 124
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 119
Number of retired or separated participants receiving benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 119
2017: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2017 401k membership
Total participants, beginning-of-year 2017-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 124
Number of retired or separated participants receiving benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 124
2016: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2016 401k membership
Total participants, beginning-of-year 2016-01-01 122
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 123
Number of retired or separated participants receiving benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 123
2015: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2015 401k membership
Total participants, beginning-of-year 2015-01-01 131
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 122
Number of retired or separated participants receiving benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 122
2014: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2014 401k membership
Total participants, beginning-of-year 2014-01-01 148
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 130
Number of retired or separated participants receiving benefits 2014-01-01 1
Total of all active and inactive participants 2014-01-01 131
2013: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2013 401k membership
Total participants, beginning-of-year 2013-01-01 126
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 147
Number of retired or separated participants receiving benefits 2013-01-01 1
Total of all active and inactive participants 2013-01-01 148
2012: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2012 401k membership
Total participants, beginning-of-year 2012-01-01 116
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 124
Number of retired or separated participants receiving benefits 2012-01-01 2
Total of all active and inactive participants 2012-01-01 126
2011: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2011 401k membership
Total participants, beginning-of-year 2011-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 115
Number of retired or separated participants receiving benefits 2011-01-01 1
Total of all active and inactive participants 2011-01-01 116

Measure	Date	Value
2022: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2022 401k membership
Total participants, beginning-of-year	2022-01-01	88
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	70
Number of retired or separated participants receiving benefits	2022-01-01	1
Total of all active and inactive participants	2022-01-01	71
2021: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2021 401k membership
Total participants, beginning-of-year	2021-01-01	92
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	88
Total of all active and inactive participants	2021-01-01	88
2020: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2020 401k membership
Total participants, beginning-of-year	2020-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	91
Number of retired or separated participants receiving benefits	2020-01-01	1
Total of all active and inactive participants	2020-01-01	92
2018: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2018 401k membership
Total participants, beginning-of-year	2018-01-01	124
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	119
Number of retired or separated participants receiving benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	119
2017: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2017 401k membership
Total participants, beginning-of-year	2017-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	124
Number of retired or separated participants receiving benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	124
2016: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2016 401k membership
Total participants, beginning-of-year	2016-01-01	122
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	123
Number of retired or separated participants receiving benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	123
2015: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2015 401k membership
Total participants, beginning-of-year	2015-01-01	131
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	122
Number of retired or separated participants receiving benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	122
2014: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2014 401k membership
Total participants, beginning-of-year	2014-01-01	148
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	130
Number of retired or separated participants receiving benefits	2014-01-01	1
Total of all active and inactive participants	2014-01-01	131
2013: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2013 401k membership
Total participants, beginning-of-year	2013-01-01	126
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	147
Number of retired or separated participants receiving benefits	2013-01-01	1
Total of all active and inactive participants	2013-01-01	148
2012: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2012 401k membership
Total participants, beginning-of-year	2012-01-01	116
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	124
Number of retired or separated participants receiving benefits	2012-01-01	2
Total of all active and inactive participants	2012-01-01	126
2011: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2011 401k membership
Total participants, beginning-of-year	2011-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	115
Number of retired or separated participants receiving benefits	2011-01-01	1
Total of all active and inactive participants	2011-01-01	116

Form 5500 Responses for MORRISVILLE AUXILIARY HOSPITAL PLAN INC.

2022: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2018: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 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: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 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: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 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: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 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: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 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: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 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: MORRISVILLE AUXILIARY HOSPITAL PLAN INC. 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

Insurance Providers Used on plan

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

406114

Policy instance

Insurance contract or identification number	406114
Number of Individuals Covered	30
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $1,393
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,393
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00007735

Policy instance

Insurance contract or identification number	00007735
Number of Individuals Covered	71
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $40,319
Total amount of fees paid to insurance company	USD $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 $40,319
Insurance broker organization code?	3

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

17773

Policy instance

Insurance contract or identification number	17773
Number of Individuals Covered	89
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,018
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,018
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

457202

Policy instance

Insurance contract or identification number	457202
Number of Individuals Covered	37
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $1,528
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,528
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

457203

Policy instance

Insurance contract or identification number	457203
Number of Individuals Covered	37
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $460
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $460
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

582529

Policy instance

Insurance contract or identification number	582529
Number of Individuals Covered	89
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $669
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $669
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

5404110010

Policy instance

Insurance contract or identification number	5404110010
Number of Individuals Covered	90
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $864
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,643
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $864
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00007735

Policy instance

Insurance contract or identification number	00007735
Number of Individuals Covered	92
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $40,141
Total amount of fees paid to insurance company	USD $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 $40,141
Insurance broker organization code?	3

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

17773

Policy instance

Insurance contract or identification number	17773
Number of Individuals Covered	112
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,263
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,263
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

457202

Policy instance

Insurance contract or identification number	457202
Number of Individuals Covered	44
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $1,350
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,350
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

457203

Policy instance

Insurance contract or identification number	457203
Number of Individuals Covered	40
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $405
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $405
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

582529

Policy instance

Insurance contract or identification number	582529
Number of Individuals Covered	107
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $608
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $608
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

5404110010

Policy instance

Insurance contract or identification number	5404110010
Number of Individuals Covered	110
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $952
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $952
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

406114

Policy instance

Insurance contract or identification number	406114
Number of Individuals Covered	36
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $1,631
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,631
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00007735

Policy instance

Insurance contract or identification number	00007735
Number of Individuals Covered	92
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $49,534
Total amount of fees paid to insurance company	USD $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 $49,534
Insurance broker organization code?	3

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

17773

Policy instance

Insurance contract or identification number	17773
Number of Individuals Covered	110
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,660
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,660
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

457202

Policy instance

Insurance contract or identification number	457202
Number of Individuals Covered	43
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $1,340
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,340
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

457203

Policy instance

Insurance contract or identification number	457203
Number of Individuals Covered	44
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $405
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $405
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

582529

Policy instance

Insurance contract or identification number	582529
Number of Individuals Covered	111
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $645
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $645
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

5404110010

Policy instance

Insurance contract or identification number	5404110010
Number of Individuals Covered	107
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,059
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,059
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

406114

Policy instance

Insurance contract or identification number	406114
Number of Individuals Covered	43
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $1,726
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,726
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

405320001

Policy instance

Insurance contract or identification number	405320001
Number of Individuals Covered	119
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $57,075
Total amount of fees paid to insurance company	USD $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 $57,075
Insurance broker organization code?	3

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

17773

Policy instance

Insurance contract or identification number	17773
Number of Individuals Covered	155
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,540
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,540
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

457202

Policy instance

Insurance contract or identification number	457202
Number of Individuals Covered	56
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $1,259
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,259
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

457203

Policy instance

Insurance contract or identification number	457203
Number of Individuals Covered	53
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $381
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $381
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

582529

Policy instance

Insurance contract or identification number	582529
Number of Individuals Covered	155
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $770
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $770
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

5404110010

Policy instance

Insurance contract or identification number	5404110010
Number of Individuals Covered	155
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,229
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,229
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

406114

Policy instance

Insurance contract or identification number	406114
Number of Individuals Covered	54
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $1,571
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,571
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

406114

Policy instance

Insurance contract or identification number	406114
Number of Individuals Covered	63
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $1,556
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,556
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

5404110010

Policy instance

Insurance contract or identification number	5404110010
Number of Individuals Covered	157
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,499
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,988
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,499
Insurance broker organization code?	3
Insurance broker name	AFS AGENCY

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

582529

Policy instance

Insurance contract or identification number	582529
Number of Individuals Covered	156
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $777
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $777
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

457203

Policy instance

Insurance contract or identification number	457203
Number of Individuals Covered	55
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $366
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $366
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

457202

Policy instance

Insurance contract or identification number	457202
Number of Individuals Covered	56
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $1,287
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,287
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

17773

Policy instance

Insurance contract or identification number	17773
Number of Individuals Covered	155
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,728
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,728
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

405320001

Policy instance

Insurance contract or identification number	405320001
Number of Individuals Covered	124
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $56,199
Total amount of fees paid to insurance company	USD $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 $56,199
Insurance broker organization code?	3
Insurance broker name	AFS AGENCY

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

405320001

Policy instance

Insurance contract or identification number	405320001
Number of Individuals Covered	128
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $50,418
Total amount of fees paid to insurance company	USD $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 $50,418
Insurance broker organization code?	3
Insurance broker name	AFS AGENCY

DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )

Policy contract number

17773

Policy instance

Insurance contract or identification number	17773
Number of Individuals Covered	153
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,640
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,640
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000457202

Policy instance

Insurance contract or identification number	000000457202
Number of Individuals Covered	51
Insurance policy start date	2014-07-01
Insurance policy end date	2015-07-01
Total amount of commissions paid to insurance broker	USD $1,154
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,154
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000457203

Policy instance

Insurance contract or identification number	000000457203
Number of Individuals Covered	48
Insurance policy start date	2014-10-01
Insurance policy end date	2015-10-01
Total amount of commissions paid to insurance broker	USD $352
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $352
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000582529

Policy instance

Insurance contract or identification number	000000582529
Number of Individuals Covered	149
Insurance policy start date	2014-06-01
Insurance policy end date	2015-06-01
Total amount of commissions paid to insurance broker	USD $602
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $602
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

5404110010

Policy instance

Insurance contract or identification number	5404110010
Number of Individuals Covered	129
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $1,006
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,006
Insurance broker name	AFS AGENCY

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

406114

Policy instance

Insurance contract or identification number	406114
Number of Individuals Covered	67
Insurance policy start date	2014-10-01
Insurance policy end date	2015-10-01
Total amount of commissions paid to insurance broker	USD $1,729
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,729
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

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

Policy contract number

00262999

Policy instance

Insurance contract or identification number	00262999
Number of Individuals Covered	151
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $4,229
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,229
Insurance broker organization code?	3
Insurance broker name	AFS AGENCY

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

Policy contract number

00262999

Policy instance

Insurance contract or identification number	00262999
Number of Individuals Covered	145
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $4,704
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 $14,429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,704
Insurance broker organization code?	3
Insurance broker name	AFS AGENCY

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

405320001

Policy instance

Insurance contract or identification number	405320001
Number of Individuals Covered	129
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $52,661
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 $52,661
Insurance broker organization code?	3
Insurance broker name	AFS AGENCY

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000457202

Policy instance

Insurance contract or identification number	000000457202
Number of Individuals Covered	54
Insurance policy start date	2013-06-01
Insurance policy end date	2014-06-01
Total amount of commissions paid to insurance broker	USD $1,306
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,306
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000457203

Policy instance

Insurance contract or identification number	000000457203
Number of Individuals Covered	53
Insurance policy start date	2013-06-01
Insurance policy end date	2014-06-01
Total amount of commissions paid to insurance broker	USD $364
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 $3,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $364
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000582529

Policy instance

Insurance contract or identification number	000000582529
Number of Individuals Covered	141
Insurance policy start date	2013-06-01
Insurance policy end date	2014-06-01
Total amount of commissions paid to insurance broker	USD $724
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 $7,240
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $724
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )

Policy contract number

5404110010

Policy instance

Insurance contract or identification number	5404110010
Number of Individuals Covered	122
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,171
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 name	AFS AGENCY

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000457203

Policy instance

Insurance contract or identification number	000000457203
Number of Individuals Covered	49
Insurance policy start date	2012-06-01
Insurance policy end date	2013-06-01
Total amount of commissions paid to insurance broker	USD $282
Total amount of fees paid to insurance company	USD $15
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 $2,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $203
Amount paid for insurance broker fees	15
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000457202

Policy instance

Insurance contract or identification number	000000457202
Number of Individuals Covered	50
Insurance policy start date	2013-06-01
Insurance policy end date	2014-06-01
Total amount of commissions paid to insurance broker	USD $1,004
Total amount of fees paid to insurance company	USD $36
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 $7,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $713
Amount paid for insurance broker fees	36
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

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

Policy contract number

00262999

Policy instance

Insurance contract or identification number	00262999
Number of Individuals Covered	145
Insurance policy start date	2012-09-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $4,149
Total amount of fees paid to insurance company	USD $822
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 $12,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,766
Amount paid for insurance broker fees	822
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3
Insurance broker name	HOWARD J ELIAS, INC.

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

405320001

Policy instance

Insurance contract or identification number	405320001
Number of Individuals Covered	123
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $42,376
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
Vision 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 $37,986
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000582529

Policy instance

Insurance contract or identification number	000000582529
Number of Individuals Covered	123
Insurance policy start date	2012-06-01
Insurance policy end date	2013-06-01
Total amount of commissions paid to insurance broker	USD $548
Total amount of fees paid to insurance company	USD $30
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 $5,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $397
Amount paid for insurance broker fees	30
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	ADIRONDACK FINANCIAL SERVICES

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000582529

Policy instance

Insurance contract or identification number	000000582529
Number of Individuals Covered	123
Insurance policy start date	2011-06-01
Insurance policy end date	2012-06-01
Total amount of commissions paid to insurance broker	USD $612
Total amount of fees paid to insurance company	USD $46
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $6,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $612
Amount paid for insurance broker fees	46
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	BROWN & BROWN EMPIRE STATE

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000457203

Policy instance

Insurance contract or identification number	000000457203
Number of Individuals Covered	41
Insurance policy start date	2011-06-01
Insurance policy end date	2012-06-01
Total amount of commissions paid to insurance broker	USD $313
Total amount of fees paid to insurance company	USD $23
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 $3,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $313
Amount paid for insurance broker fees	23
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000457202

Policy instance

Insurance contract or identification number	000000457202
Number of Individuals Covered	47
Insurance policy start date	2012-06-01
Insurance policy end date	2013-06-01
Total amount of commissions paid to insurance broker	USD $1,073
Total amount of fees paid to insurance company	USD $54
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 $7,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,073
Amount paid for insurance broker fees	54
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN OF NEW YORK INC

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

Policy contract number

00262999

Policy instance

Insurance contract or identification number	00262999
Number of Individuals Covered	128
Insurance policy start date	2011-09-01
Insurance policy end date	2012-08-31
Total amount of commissions paid to insurance broker	USD $3,392
Total amount of fees paid to insurance company	USD $682
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 $10,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,358
Amount paid for insurance broker fees	682
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3
Insurance broker name	ELIAS HOWARD J INC

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

405320001

Policy instance

Insurance contract or identification number	405320001
Number of Individuals Covered	115
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $42,469
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 $42,469
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000457203

Policy instance

Insurance contract or identification number	000000457203
Number of Individuals Covered	41
Insurance policy start date	2010-06-01
Insurance policy end date	2011-06-01
Total amount of commissions paid to insurance broker	USD $259
Total amount of fees paid to insurance company	USD $19
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 $2,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000457202

Policy instance

Insurance contract or identification number	000000457202
Number of Individuals Covered	46
Insurance policy start date	2010-06-01
Insurance policy end date	2011-06-01
Total amount of commissions paid to insurance broker	USD $1,008
Total amount of fees paid to insurance company	USD $50
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 $6,300
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

00262999

Policy instance

Insurance contract or identification number	00262999
Number of Individuals Covered	115
Insurance policy start date	2010-09-01
Insurance policy end date	2011-08-31
Total amount of commissions paid to insurance broker	USD $3,257
Total amount of fees paid to insurance company	USD $632
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 $9,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

405320001

Policy instance

Insurance contract or identification number	405320001
Number of Individuals Covered	117
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $39,598
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

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000457203

Policy instance

Insurance contract or identification number	000000457203
Number of Individuals Covered	41
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $214
Total amount of fees paid to insurance company	USD $20
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $214
Amount paid for insurance broker fees	20
Additional information about fees paid to insurance broker	ADDITIONAL FEES PAID
Insurance broker organization code?	3
Insurance broker name	AUSTIN & CO., INC.

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

000000582529

Policy instance

Insurance contract or identification number	000000582529
Number of Individuals Covered	110
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $474
Total amount of fees paid to insurance company	USD $43
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $474
Amount paid for insurance broker fees	43
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	AUSTIN & CO., INC.

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

Policy contract number

00262999

Policy instance

Insurance contract or identification number	00262999
Number of Individuals Covered	101
Insurance policy start date	2009-09-01
Insurance policy end date	2010-08-31
Total amount of commissions paid to insurance broker	USD $3,355
Total amount of fees paid to insurance company	USD $254
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 $2,008
Insurance broker organization code?	3
Amount paid for insurance broker fees	254
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker name	HOWARD J ELIAS INC

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

405320001

Policy instance

Insurance contract or identification number	405320001
Number of Individuals Covered	110
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $41,028
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 $39,153
Insurance broker organization code?	3
Insurance broker name	AUSTIN & CO., INC.

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Company Name:	MORRISVILLE AUX OF STATEUNIVCOLLEGE OF AGRI AND TECH AT MORRISVILLEINC
Employer identification number (EIN):	150560110
NAIC Classification:	611000