401k Plan data: SRC TOTAL CARE PLAN plan

SRC TOTAL CARE PLAN 401k Plan overview

Plan Name	SRC TOTAL CARE PLAN
Plan identification number	507

SRC TOTAL CARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

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

Company Name: SRC, INC.

Employer identification number (EIN): 150589832

NAIC Classification: 541700

Additional information about SRC, INC.

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1996-10-22

Company Identification Number: 2077004

Legal Registered Office Address: 7502 ROUND POND ROAD
Onondaga
N. SYRACUSE
United States of America (USA)
13212

More information about SRC, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SRC TOTAL CARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
507 2022-01-01 GWENDOLYN SYKES 2023-07-27
507 2021-01-01
507 2021-01-01 GWENDOLYN SYKES 2023-12-27
507 2020-01-01
507 2019-01-01
507 2019-01-01 GWENDOLYN SYKES 2023-12-27
507 2018-01-01 GWENDOLYN SYKES 2023-12-18
507 2017-01-01 PHILIP FAZIO
507 2017-01-01 GWENDOLYN SYKES 2023-12-27
507 2016-01-01 PHILIP FAZIO
507 2016-01-01 GWENDOLYN SYKES 2023-12-27
507 2015-01-01 PHILIP FAZIO
507 2014-01-01 PHILIP FAZIO
507 2013-01-01 PHILIP FAZIO
507 2012-01-01 PHILIP FAZIO
507 2011-01-01 PHILIP FAZIO
507 2009-01-01 PAULINE C. FULLER

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
507	2022-01-01	GWENDOLYN SYKES	2023-07-27
507	2021-01-01
507	2021-01-01	GWENDOLYN SYKES	2023-12-27
507	2020-01-01
507	2019-01-01
507	2019-01-01	GWENDOLYN SYKES	2023-12-27
507	2018-01-01	GWENDOLYN SYKES	2023-12-18
507	2017-01-01	PHILIP FAZIO
507	2017-01-01	GWENDOLYN SYKES	2023-12-27
507	2016-01-01	PHILIP FAZIO
507	2016-01-01	GWENDOLYN SYKES	2023-12-27
507	2015-01-01	PHILIP FAZIO
507	2014-01-01	PHILIP FAZIO
507	2013-01-01	PHILIP FAZIO
507	2012-01-01	PHILIP FAZIO
507	2011-01-01	PHILIP FAZIO
507	2009-01-01	PAULINE C. FULLER

Plan Statistics for SRC TOTAL CARE PLAN

401k plan membership statisitcs for SRC TOTAL CARE PLAN

Measure Date Value
2022: SRC TOTAL CARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 1,580
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 1,331
Number of retired or separated participants receiving benefits 2022-01-01 152
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 1,483
2021: SRC TOTAL CARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 1,643
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 1,464
Number of retired or separated participants receiving benefits 2021-01-01 57
Number of other retired or separated participants entitled to future benefits 2021-01-01 43
Total of all active and inactive participants 2021-01-01 1,564
Total participants 2021-01-01 1,564
Number of employers contributing to the scheme 2021-01-01 0
2020: SRC TOTAL CARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 1,607
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 1,523
Number of retired or separated participants receiving benefits 2020-01-01 7
Number of other retired or separated participants entitled to future benefits 2020-01-01 113
Total of all active and inactive participants 2020-01-01 1,643
Total participants 2020-01-01 1,643
2019: SRC TOTAL CARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,269
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 1,588
Number of other retired or separated participants entitled to future benefits 2019-01-01 19
Total of all active and inactive participants 2019-01-01 1,607
Total participants 2019-01-01 1,607
Number of employers contributing to the scheme 2019-01-01 0
Number of retired or separated participants receiving benefits 2019-01-01 19
2018: SRC TOTAL CARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 1,080
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 1,252
Number of retired or separated participants receiving benefits 2018-01-01 17
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 1,269
2017: SRC TOTAL CARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 1,108
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 1,064
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 16
Total of all active and inactive participants 2017-01-01 1,080
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 1,080
2016: SRC TOTAL CARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,015
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 1,066
Number of retired or separated participants receiving benefits 2016-01-01 26
Number of other retired or separated participants entitled to future benefits 2016-01-01 14
Total of all active and inactive participants 2016-01-01 1,106
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 2
Total participants 2016-01-01 1,108
2015: SRC TOTAL CARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 987
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 966
Number of retired or separated participants receiving benefits 2015-01-01 32
Number of other retired or separated participants entitled to future benefits 2015-01-01 15
Total of all active and inactive participants 2015-01-01 1,013
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 2
Total participants 2015-01-01 1,015
2014: SRC TOTAL CARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 903
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 948
Number of retired or separated participants receiving benefits 2014-01-01 27
Number of other retired or separated participants entitled to future benefits 2014-01-01 10
Total of all active and inactive participants 2014-01-01 985
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 2
Total participants 2014-01-01 987
2013: SRC TOTAL CARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 990
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 832
Number of retired or separated participants receiving benefits 2013-01-01 53
Number of other retired or separated participants entitled to future benefits 2013-01-01 16
Total of all active and inactive participants 2013-01-01 901
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 2
Total participants 2013-01-01 903
Number of participants with account balances 2013-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: SRC TOTAL CARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,193
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 940
Number of retired or separated participants receiving benefits 2012-01-01 34
Number of other retired or separated participants entitled to future benefits 2012-01-01 16
Total of all active and inactive participants 2012-01-01 990
Total participants 2012-01-01 990
2011: SRC TOTAL CARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,154
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,151
Number of retired or separated participants receiving benefits 2011-01-01 30
Number of other retired or separated participants entitled to future benefits 2011-01-01 12
Total of all active and inactive participants 2011-01-01 1,193
2009: SRC TOTAL CARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 992
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 1,025
Number of retired or separated participants receiving benefits 2009-01-01 28
Number of other retired or separated participants entitled to future benefits 2009-01-01 11
Total of all active and inactive participants 2009-01-01 1,064

Measure	Date	Value
2022: SRC TOTAL CARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	1,580
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	1,331
Number of retired or separated participants receiving benefits	2022-01-01	152
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	1,483
2021: SRC TOTAL CARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	1,643
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	1,464
Number of retired or separated participants receiving benefits	2021-01-01	57
Number of other retired or separated participants entitled to future benefits	2021-01-01	43
Total of all active and inactive participants	2021-01-01	1,564
Total participants	2021-01-01	1,564
Number of employers contributing to the scheme	2021-01-01	0
2020: SRC TOTAL CARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	1,607
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,523
Number of retired or separated participants receiving benefits	2020-01-01	7
Number of other retired or separated participants entitled to future benefits	2020-01-01	113
Total of all active and inactive participants	2020-01-01	1,643
Total participants	2020-01-01	1,643
2019: SRC TOTAL CARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,269
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	1,588
Number of other retired or separated participants entitled to future benefits	2019-01-01	19
Total of all active and inactive participants	2019-01-01	1,607
Total participants	2019-01-01	1,607
Number of employers contributing to the scheme	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	19
2018: SRC TOTAL CARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	1,080
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,252
Number of retired or separated participants receiving benefits	2018-01-01	17
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	1,269
2017: SRC TOTAL CARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,108
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,064
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	16
Total of all active and inactive participants	2017-01-01	1,080
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	1,080
2016: SRC TOTAL CARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,015
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,066
Number of retired or separated participants receiving benefits	2016-01-01	26
Number of other retired or separated participants entitled to future benefits	2016-01-01	14
Total of all active and inactive participants	2016-01-01	1,106
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	2
Total participants	2016-01-01	1,108
2015: SRC TOTAL CARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	987
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	966
Number of retired or separated participants receiving benefits	2015-01-01	32
Number of other retired or separated participants entitled to future benefits	2015-01-01	15
Total of all active and inactive participants	2015-01-01	1,013
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	2
Total participants	2015-01-01	1,015
2014: SRC TOTAL CARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	903
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	948
Number of retired or separated participants receiving benefits	2014-01-01	27
Number of other retired or separated participants entitled to future benefits	2014-01-01	10
Total of all active and inactive participants	2014-01-01	985
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	2
Total participants	2014-01-01	987
2013: SRC TOTAL CARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	990
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	832
Number of retired or separated participants receiving benefits	2013-01-01	53
Number of other retired or separated participants entitled to future benefits	2013-01-01	16
Total of all active and inactive participants	2013-01-01	901
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	2
Total participants	2013-01-01	903
Number of participants with account balances	2013-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: SRC TOTAL CARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,193
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	940
Number of retired or separated participants receiving benefits	2012-01-01	34
Number of other retired or separated participants entitled to future benefits	2012-01-01	16
Total of all active and inactive participants	2012-01-01	990
Total participants	2012-01-01	990
2011: SRC TOTAL CARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,154
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,151
Number of retired or separated participants receiving benefits	2011-01-01	30
Number of other retired or separated participants entitled to future benefits	2011-01-01	12
Total of all active and inactive participants	2011-01-01	1,193
2009: SRC TOTAL CARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	992
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	1,025
Number of retired or separated participants receiving benefits	2009-01-01	28
Number of other retired or separated participants entitled to future benefits	2009-01-01	11
Total of all active and inactive participants	2009-01-01	1,064

Financial Data on SRC TOTAL CARE PLAN

Measure	Date	Value
2016 : SRC TOTAL CARE PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$470,578
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$262,292
Total income from all sources (including contributions)	2016-12-31	$10,464,130
Total loss/gain on sale of assets	2016-12-31	$99,286
Total of all expenses incurred	2016-12-31	$13,219,004
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$12,909,806
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$10,358,371
Value of total assets at end of year	2016-12-31	$545,578
Value of total assets at beginning of year	2016-12-31	$3,092,166
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$309,198
Total interest from all sources	2016-12-31	$338
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$21,831
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2016-12-31	$21,831
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$2,000,000
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$4,570,729
Participant contributions at end of year	2016-12-31	$0
Participant contributions at beginning of year	2016-12-31	$619
Administrative expenses (other) incurred	2016-12-31	$16,464
Total non interest bearing cash at end of year	2016-12-31	$108,174
Total non interest bearing cash at beginning of year	2016-12-31	$85,264
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Value of net income/loss	2016-12-31	$-2,754,874
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$75,000
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$2,829,874
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2016-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2016-12-31	$1,923,927
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2016-12-31	$338
Expenses. Payments to insurance carriers foe the provision of benefits	2016-12-31	$12,157,834
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2016-12-31	$-15,696
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2016-12-31	No
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Contributions received in cash from employer	2016-12-31	$5,787,642
Employer contributions (assets) at end of year	2016-12-31	$437,404
Employer contributions (assets) at beginning of year	2016-12-31	$1,082,356
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$751,972
Contract administrator fees	2016-12-31	$292,734
Liabilities. Value of benefit claims payable at end of year	2016-12-31	$470,578
Liabilities. Value of benefit claims payable at beginning of year	2016-12-31	$262,292
Did the plan have assets held for investment	2016-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
Aggregate proceeds on sale of assets	2016-12-31	$2,808,143
Aggregate carrying amount (costs) on sale of assets	2016-12-31	$2,708,857
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2016-12-31	Disclaimer
Accountancy firm name	2016-12-31	FUST CHARLES CHAMBERS LLP
Accountancy firm EIN	2016-12-31	161226221
2015 : SRC TOTAL CARE PLAN 2015 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2015-12-31	$261
Total unrealized appreciation/depreciation of assets	2015-12-31	$261
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$262,292
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$197,728
Total income from all sources (including contributions)	2015-12-31	$13,144,548
Total loss/gain on sale of assets	2015-12-31	$13,939
Total of all expenses incurred	2015-12-31	$12,875,904
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$12,578,587
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$13,141,044
Value of total assets at end of year	2015-12-31	$3,092,166
Value of total assets at beginning of year	2015-12-31	$2,758,958
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$297,317
Total interest from all sources	2015-12-31	$649
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$72,521
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2015-12-31	$72,521
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$2,000,000
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$4,093,094
Participant contributions at end of year	2015-12-31	$619
Participant contributions at beginning of year	2015-12-31	$513
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2015-12-31	$3,139
Administrative expenses (other) incurred	2015-12-31	$17,063
Total non interest bearing cash at end of year	2015-12-31	$85,264
Total non interest bearing cash at beginning of year	2015-12-31	$89,918
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$268,644
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$2,829,874
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$2,561,230
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2015-12-31	$1,923,927
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$1,769,399
Income. Interest from US Government securities	2015-12-31	$211
Income. Interest from corporate debt instruments	2015-12-31	$407
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2015-12-31	$31
Expenses. Payments to insurance carriers foe the provision of benefits	2015-12-31	$11,825,505
Asset value of US Government securities at beginning of year	2015-12-31	$69,284
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$-83,866
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2015-12-31	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$9,047,950
Employer contributions (assets) at end of year	2015-12-31	$1,082,356
Employer contributions (assets) at beginning of year	2015-12-31	$693,282
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$753,082
Asset. Corporate debt instrument debt (other) at beginning of year	2015-12-31	$133,423
Contract administrator fees	2015-12-31	$280,254
Liabilities. Value of benefit claims payable at end of year	2015-12-31	$262,292
Liabilities. Value of benefit claims payable at beginning of year	2015-12-31	$197,728
Did the plan have assets held for investment	2015-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Aggregate proceeds on sale of assets	2015-12-31	$202,967
Aggregate carrying amount (costs) on sale of assets	2015-12-31	$189,028
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	FUST CHARLES CHAMBERS LLP
Accountancy firm EIN	2015-12-31	161226221
2014 : SRC TOTAL CARE PLAN 2014 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2014-12-31	$-5,992
Total unrealized appreciation/depreciation of assets	2014-12-31	$-5,992
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$197,728
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$116,736
Total income from all sources (including contributions)	2014-12-31	$10,476,769
Total loss/gain on sale of assets	2014-12-31	$-199
Total of all expenses incurred	2014-12-31	$10,658,560
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$10,365,839
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$10,410,721
Value of total assets at end of year	2014-12-31	$2,758,958
Value of total assets at beginning of year	2014-12-31	$2,859,757
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$292,721
Total interest from all sources	2014-12-31	$10,061
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$67,040
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2014-12-31	$67,040
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$2,000,000
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$3,911,936
Participant contributions at end of year	2014-12-31	$513
Participant contributions at beginning of year	2014-12-31	$518
Value of other receiveables (less allowance for doubtful accounts) at end of year	2014-12-31	$3,139
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2014-12-31	$3,675
Administrative expenses (other) incurred	2014-12-31	$17,237
Total non interest bearing cash at end of year	2014-12-31	$89,918
Total non interest bearing cash at beginning of year	2014-12-31	$99,350
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$-181,791
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$2,561,230
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$2,743,021
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2014-12-31	$1,769,399
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2014-12-31	$1,752,760
Income. Interest from US Government securities	2014-12-31	$3,621
Income. Interest from corporate debt instruments	2014-12-31	$6,432
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2014-12-31	$8
Expenses. Payments to insurance carriers foe the provision of benefits	2014-12-31	$9,713,909
Asset value of US Government securities at end of year	2014-12-31	$69,284
Asset value of US Government securities at beginning of year	2014-12-31	$100,502
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$-4,862
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$6,498,785
Employer contributions (assets) at end of year	2014-12-31	$693,282
Employer contributions (assets) at beginning of year	2014-12-31	$765,978
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$651,930
Asset. Corporate debt instrument debt (other) at end of year	2014-12-31	$133,423
Asset. Corporate debt instrument debt (other) at beginning of year	2014-12-31	$136,974
Contract administrator fees	2014-12-31	$275,484
Liabilities. Value of benefit claims payable at end of year	2014-12-31	$197,728
Liabilities. Value of benefit claims payable at beginning of year	2014-12-31	$116,736
Did the plan have assets held for investment	2014-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Aggregate proceeds on sale of assets	2014-12-31	$28,777
Aggregate carrying amount (costs) on sale of assets	2014-12-31	$28,976
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	FUST CHARLES CHAMBERS LLP
Accountancy firm EIN	2014-12-31	161226221
2013 : SRC TOTAL CARE PLAN 2013 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2013-12-31	$-9,338
Total unrealized appreciation/depreciation of assets	2013-12-31	$-9,338
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$116,736
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$93,434
Total income from all sources (including contributions)	2013-12-31	$12,757,210
Total loss/gain on sale of assets	2013-12-31	$-499
Total of all expenses incurred	2013-12-31	$12,704,365
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$12,401,021
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$12,480,047
Value of total assets at end of year	2013-12-31	$2,859,757
Value of total assets at beginning of year	2013-12-31	$2,783,610
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$303,344
Total interest from all sources	2013-12-31	$11,495
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$56,498
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2013-12-31	$56,498
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$2,000,000
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$3,949,366
Participant contributions at end of year	2013-12-31	$518
Value of other receiveables (less allowance for doubtful accounts) at end of year	2013-12-31	$3,675
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2013-12-31	$4,209
Administrative expenses (other) incurred	2013-12-31	$16,195
Total non interest bearing cash at end of year	2013-12-31	$99,350
Total non interest bearing cash at beginning of year	2013-12-31	$74,560
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$52,845
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$2,743,021
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$2,690,176
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2013-12-31	$1,752,760
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2013-12-31	$1,430,118
Income. Interest from US Government securities	2013-12-31	$4,949
Income. Interest from corporate debt instruments	2013-12-31	$6,533
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2013-12-31	$13
Expenses. Payments to insurance carriers foe the provision of benefits	2013-12-31	$11,755,106
Asset value of US Government securities at end of year	2013-12-31	$100,502
Asset value of US Government securities at beginning of year	2013-12-31	$110,142
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2013-12-31	$219,007
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Contributions received in cash from employer	2013-12-31	$8,530,681
Employer contributions (assets) at end of year	2013-12-31	$765,978
Employer contributions (assets) at beginning of year	2013-12-31	$997,372
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$645,915
Asset. Corporate debt instrument debt (other) at end of year	2013-12-31	$136,974
Asset. Corporate debt instrument debt (other) at beginning of year	2013-12-31	$167,209
Contract administrator fees	2013-12-31	$287,149
Liabilities. Value of benefit claims payable at end of year	2013-12-31	$116,736
Liabilities. Value of benefit claims payable at beginning of year	2013-12-31	$93,434
Did the plan have assets held for investment	2013-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Aggregate proceeds on sale of assets	2013-12-31	$30,537
Aggregate carrying amount (costs) on sale of assets	2013-12-31	$31,036
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2013-12-31	Disclaimer
Accountancy firm name	2013-12-31	FUST CHARLES CHAMBERS LLP
Accountancy firm EIN	2013-12-31	161226221
2012 : SRC TOTAL CARE PLAN 2012 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2012-12-31	$-6,632
Total unrealized appreciation/depreciation of assets	2012-12-31	$-6,632
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$93,434
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$319,126
Total income from all sources (including contributions)	2012-12-31	$12,949,910
Total loss/gain on sale of assets	2012-12-31	$6,569
Total of all expenses incurred	2012-12-31	$12,395,380
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$12,067,509
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$12,775,976
Value of total assets at end of year	2012-12-31	$2,783,610
Value of total assets at beginning of year	2012-12-31	$2,454,772
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$327,871
Total interest from all sources	2012-12-31	$17,655
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$32,100
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2012-12-31	$32,100
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$2,000,000
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$4,008,871
Participant contributions at beginning of year	2012-12-31	$2,468
Value of other receiveables (less allowance for doubtful accounts) at end of year	2012-12-31	$4,209
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2012-12-31	$6,138
Administrative expenses (other) incurred	2012-12-31	$16,126
Total non interest bearing cash at end of year	2012-12-31	$74,560
Total non interest bearing cash at beginning of year	2012-12-31	$96,948
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$554,530
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$2,690,176
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$2,135,646
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2012-12-31	$1,430,118
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-12-31	$1,178,128
Income. Interest from US Government securities	2012-12-31	$5,284
Income. Interest from corporate debt instruments	2012-12-31	$12,371
Expenses. Payments to insurance carriers foe the provision of benefits	2012-12-31	$11,403,903
Asset value of US Government securities at end of year	2012-12-31	$110,142
Asset value of US Government securities at beginning of year	2012-12-31	$119,457
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2012-12-31	$124,242
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$8,767,105
Employer contributions (assets) at end of year	2012-12-31	$997,372
Employer contributions (assets) at beginning of year	2012-12-31	$730,702
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$663,606
Asset. Corporate debt instrument debt (other) at end of year	2012-12-31	$167,209
Asset. Corporate debt instrument debt (other) at beginning of year	2012-12-31	$320,931
Contract administrator fees	2012-12-31	$311,745
Liabilities. Value of benefit claims payable at end of year	2012-12-31	$93,434
Liabilities. Value of benefit claims payable at beginning of year	2012-12-31	$319,126
Did the plan have assets held for investment	2012-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Aggregate proceeds on sale of assets	2012-12-31	$162,974
Aggregate carrying amount (costs) on sale of assets	2012-12-31	$156,405
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	FUST CHARLES CHAMBERS L.L.P.
Accountancy firm EIN	2012-12-31	161226221
2011 : SRC TOTAL CARE PLAN 2011 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2011-12-31	$-837
Total unrealized appreciation/depreciation of assets	2011-12-31	$-837
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$319,126
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$298,590
Total income from all sources (including contributions)	2011-12-31	$12,429,892
Total loss/gain on sale of assets	2011-12-31	$441
Total of all expenses incurred	2011-12-31	$12,160,432
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$11,729,688
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$12,409,978
Value of total assets at end of year	2011-12-31	$2,454,772
Value of total assets at beginning of year	2011-12-31	$2,164,776
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$430,744
Total interest from all sources	2011-12-31	$20,812
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$21,963
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2011-12-31	$21,963
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$2,000,000
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$3,835,410
Participant contributions at end of year	2011-12-31	$2,468
Participant contributions at beginning of year	2011-12-31	$813
Value of other receiveables (less allowance for doubtful accounts) at end of year	2011-12-31	$6,138
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2011-12-31	$6,711
Administrative expenses (other) incurred	2011-12-31	$14,425
Total non interest bearing cash at end of year	2011-12-31	$96,948
Total non interest bearing cash at beginning of year	2011-12-31	$90,462
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$269,460
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$2,135,646
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$1,866,186
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2011-12-31	$1,178,128
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2011-12-31	$908,670
Income. Interest from US Government securities	2011-12-31	$6,724
Income. Interest from corporate debt instruments	2011-12-31	$14,088
Expenses. Payments to insurance carriers foe the provision of benefits	2011-12-31	$10,989,321
Asset value of US Government securities at end of year	2011-12-31	$119,457
Asset value of US Government securities at beginning of year	2011-12-31	$152,176
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2011-12-31	$-22,465
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2011-12-31	No
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Contributions received in cash from employer	2011-12-31	$8,574,568
Employer contributions (assets) at end of year	2011-12-31	$730,702
Employer contributions (assets) at beginning of year	2011-12-31	$659,530
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$740,367
Asset. Corporate debt instrument debt (other) at end of year	2011-12-31	$320,931
Asset. Corporate debt instrument debt (other) at beginning of year	2011-12-31	$346,414
Contract administrator fees	2011-12-31	$416,319
Liabilities. Value of benefit claims payable at end of year	2011-12-31	$319,126
Liabilities. Value of benefit claims payable at beginning of year	2011-12-31	$298,590
Did the plan have assets held for investment	2011-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Aggregate proceeds on sale of assets	2011-12-31	$57,806
Aggregate carrying amount (costs) on sale of assets	2011-12-31	$57,365
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	FUST CHARLES CHAMBERS L.L.P.
Accountancy firm EIN	2011-12-31	161226221
2010 : SRC TOTAL CARE PLAN 2010 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2010-12-31	$-7,315
Total unrealized appreciation/depreciation of assets	2010-12-31	$-7,315
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$298,590
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$11,171
Total income from all sources (including contributions)	2010-12-31	$9,926,791
Total loss/gain on sale of assets	2010-12-31	$23,503
Total of all expenses incurred	2010-12-31	$11,299,409
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$10,858,546
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$9,813,527
Value of total assets at end of year	2010-12-31	$2,164,776
Value of total assets at beginning of year	2010-12-31	$3,249,975
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$440,863
Total interest from all sources	2010-12-31	$32,253
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$17,826
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2010-12-31	$17,826
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$2,000,000
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$3,353,888
Participant contributions at end of year	2010-12-31	$813
Participant contributions at beginning of year	2010-12-31	$1,520
Value of other receiveables (less allowance for doubtful accounts) at end of year	2010-12-31	$6,711
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2010-12-31	$11,419
Administrative expenses (other) incurred	2010-12-31	$18,260
Total non interest bearing cash at end of year	2010-12-31	$90,462
Total non interest bearing cash at beginning of year	2010-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$-1,372,618
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$1,866,186
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$3,238,804
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2010-12-31	$908,670
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2010-12-31	$1,701,936
Income. Interest from US Government securities	2010-12-31	$15,295
Income. Interest from corporate debt instruments	2010-12-31	$16,958
Expenses. Payments to insurance carriers foe the provision of benefits	2010-12-31	$10,222,388
Asset value of US Government securities at end of year	2010-12-31	$152,176
Asset value of US Government securities at beginning of year	2010-12-31	$478,534
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2010-12-31	$46,997
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$6,459,639
Employer contributions (assets) at end of year	2010-12-31	$659,530
Employer contributions (assets) at beginning of year	2010-12-31	$593,479
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$636,158
Asset. Corporate debt instrument debt (other) at end of year	2010-12-31	$346,414
Asset. Corporate debt instrument debt (other) at beginning of year	2010-12-31	$463,087
Contract administrator fees	2010-12-31	$422,603
Liabilities. Value of benefit claims payable at end of year	2010-12-31	$298,590
Liabilities. Value of benefit claims payable at beginning of year	2010-12-31	$11,171
Did the plan have assets held for investment	2010-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Aggregate proceeds on sale of assets	2010-12-31	$459,220
Aggregate carrying amount (costs) on sale of assets	2010-12-31	$435,717
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	FUST CHARLES CHAMBERS L.L.P.
Accountancy firm EIN	2010-12-31	161226221

Form 5500 Responses for SRC TOTAL CARE PLAN

2022: SRC TOTAL CARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: SRC TOTAL CARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: SRC TOTAL CARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: SRC TOTAL CARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: SRC TOTAL CARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: SRC TOTAL CARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	Yes
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: SRC TOTAL CARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	Yes
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: SRC TOTAL CARE PLAN 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 funding arrangement – Trust	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: SRC TOTAL CARE 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 funding arrangement – Trust	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: SRC TOTAL CARE 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 funding arrangement – Trust	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: SRC TOTAL CARE 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 funding arrangement – Trust	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: SRC TOTAL CARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: SRC TOTAL CARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

ETB011846

Policy instance

Insurance contract or identification number	ETB011846
Number of Individuals Covered	0
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $2,001
Total amount of fees paid to insurance company	USD $400
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,001
Amount paid for insurance broker fees	400
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

00422816

Policy instance

Insurance contract or identification number	00422816
Number of Individuals Covered	1423
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $121,841
Total amount of fees paid to insurance company	USD $38,406
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT, OPTIONAL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,294,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $121,841
Amount paid for insurance broker fees	38406
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

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

Policy contract number

00581974

Policy instance

Insurance contract or identification number	00581974
Number of Individuals Covered	146
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,400
Total amount of fees paid to insurance company	USD $105
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $87,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,400
Amount paid for insurance broker fees	105
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

30085398

Policy instance

Insurance contract or identification number	30085398
Number of Individuals Covered	1173
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $220,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

ETB-011846

Policy instance

Insurance contract or identification number	ETB-011846
Number of Individuals Covered	0
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $2,001
Total amount of fees paid to insurance company	USD $200
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,001
Amount paid for insurance broker fees	200
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

B7366

Policy instance

Insurance contract or identification number	B7366
Number of Individuals Covered	1539
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $118,797
Total amount of fees paid to insurance company	USD $27,227
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	OPTIONAL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,273,597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $118,797
Amount paid for insurance broker fees	27227
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

30085398

Policy instance

Insurance contract or identification number	30085398
Number of Individuals Covered	1208
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $30,430
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $234,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	30430
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	5

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

Policy contract number

00581974

Policy instance

Insurance contract or identification number	00581974
Number of Individuals Covered	137
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $674
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,449
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $667
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

30085398

Policy instance

Insurance contract or identification number	30085398
Number of Individuals Covered	1315
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $7,440
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $262,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7440
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	5

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

Policy contract number

B7366

Policy instance

Insurance contract or identification number	B7366
Number of Individuals Covered	1694
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $125,228
Total amount of fees paid to insurance company	USD $23,390
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	OPTIONAL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,368,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125,228
Amount paid for insurance broker fees	23390
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

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

Policy contract number

B7366

Policy instance

Insurance contract or identification number	B7366
Number of Individuals Covered	1655
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $116,963
Total amount of fees paid to insurance company	USD $23,097
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	OPTIONAL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,255,373
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $116,963
Amount paid for insurance broker fees	23097
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

ETB-011846

Policy instance

Insurance contract or identification number	ETB-011846
Number of Individuals Covered	0
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $2,001
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,001
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

30085398

Policy instance

Insurance contract or identification number	30085398
Number of Individuals Covered	1275
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $87,588
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $245,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	87588
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $87,588

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

Policy contract number

B7366

Policy instance

Insurance contract or identification number	B7366
Number of Individuals Covered	1367
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $123,159
Total amount of fees paid to insurance company	USD $22,219
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT, OPTIONAL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,204,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $123,159
Amount paid for insurance broker fees	22219
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

001 002 C02 C0B

Policy instance

Insurance contract or identification number	001 002 C02 C0B
Number of Individuals Covered	2419
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $161,681
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

0113163

Policy instance

Insurance contract or identification number	0113163
Number of Individuals Covered	9
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $18,988
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $421,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	18988
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

ETB-011846

Policy instance

Insurance contract or identification number	ETB-011846
Number of Individuals Covered	0
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $2,272
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,272
Insurance broker organization code?	3

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

Policy contract number

45257

Policy instance

Insurance contract or identification number	45257
Number of Individuals Covered	1065
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

45257

Policy instance

Insurance contract or identification number	45257
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Health Insurance Welfare Benefit	Yes
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

514176,814176,4

Policy instance

Insurance contract or identification number	514176,814176,4
Number of Individuals Covered	0
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

ETB011846

Policy instance

Insurance contract or identification number	ETB011846
Number of Individuals Covered	0
Insurance policy start date	2016-10-01
Insurance policy end date	2017-09-30
Total amount of commissions paid to insurance broker	USD $1,181
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,181
Insurance broker organization code?	3

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

Policy contract number

0113163

Policy instance

Insurance contract or identification number	0113163
Number of Individuals Covered	67
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $47,326
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,143,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	47326
Additional information about fees paid to insurance broker	COMMISSIONS PAID
Insurance broker organization code?	3
Total amount of commissions paid to insurance broker	USD $47,326
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Commission paid to Insurance Broker	USD $47,326
Insurance broker name	BROWN & BROWN OF NEW YORK

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

Policy contract number

B7366

Policy instance

Insurance contract or identification number	B7366
Number of Individuals Covered	1214
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $119,672
Total amount of fees paid to insurance company	USD $21,108
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT, OPTIONAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $1,080,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $119,672
Amount paid for insurance broker fees	21108
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Insurance broker name	BROWN & BROWN OF NEW YORK

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

001,002,C02,COB

Policy instance

Insurance contract or identification number	001,002,C02,COB
Number of Individuals Covered	2138
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT, OPTIONAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $138,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

001,002,C02,COB

Policy instance

Insurance contract or identification number	001,002,C02,COB
Number of Individuals Covered	2002
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $131,505
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

B7366

Policy instance

Insurance contract or identification number	B7366
Number of Individuals Covered	1124
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $109,968
Total amount of fees paid to insurance company	USD $2,174
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT, OPTIONAL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $987,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $109,968
Amount paid for insurance broker fees	2174
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

0113163

Policy instance

Insurance contract or identification number	0113163
Number of Individuals Covered	54
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $31,700
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $744,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,700
Insurance broker organization code?	3

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

ETB011846

Policy instance

Insurance contract or identification number	ETB011846
Number of Individuals Covered	0
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $2,158
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,158
Insurance broker organization code?	3

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

Policy contract number

514176,814176,4

Policy instance

Insurance contract or identification number	514176,814176,4
Number of Individuals Covered	0
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

ETB011846

Policy instance

Insurance contract or identification number	ETB011846
Number of Individuals Covered	0
Insurance policy start date	2016-09-01
Insurance policy end date	2016-09-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

001,002,C02,COB

Policy instance

Insurance contract or identification number	001,002,C02,COB
Number of Individuals Covered	2414
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $126,985
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

0113163

Policy instance

Insurance contract or identification number	0113163
Number of Individuals Covered	36
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of fees paid to insurance company	USD $14,401
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $326,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	14401
Additional information about fees paid to insurance broker	COMMISSIONS PAID
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

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

Policy contract number

B7366

Policy instance

Insurance contract or identification number	B7366
Number of Individuals Covered	1031
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $104,103
Total amount of fees paid to insurance company	USD $27,266
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT, OPTIONAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $921,698
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $104,103
Amount paid for insurance broker fees	27266
Additional information about fees paid to insurance broker	FESS PAID
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN OF NEW YORK, INC.

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

Policy contract number

514176,814176,4

Policy instance

Insurance contract or identification number	514176,814176,4
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Health Insurance Welfare Benefit	Yes
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

00113163

Policy instance

Insurance contract or identification number	00113163
Number of Individuals Covered	14
Insurance policy start date	2014-10-01
Insurance policy end date	2014-12-31
Total amount of fees paid to insurance company	USD $1,489
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1489
Additional information about fees paid to insurance broker	COMMISSIONS PAID
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

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

Policy contract number

B7366

Policy instance

Insurance contract or identification number	B7366
Number of Individuals Covered	997
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $89,883
Total amount of fees paid to insurance company	USD $27,851
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT, OPTIONAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $1,744,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $89,883
Amount paid for insurance broker fees	27851
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN OF NEW YORK INC

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

001, 002, C02,

Policy instance

Insurance contract or identification number	001, 002, C02,
Number of Individuals Covered	2427
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $124,336
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

514176, 814176,

Policy instance

Insurance contract or identification number	514176, 814176,
Health Insurance Welfare Benefit	Yes

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

Policy contract number

514176, 814176,

Policy instance

Insurance contract or identification number	514176, 814176,
Number of Individuals Covered	32
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

001, 002, C02,

Policy instance

Insurance contract or identification number	001, 002, C02,
Number of Individuals Covered	2512
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of fees paid to insurance company	USD $5,899
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $131,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	5899
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3
Insurance broker name	HM LIFE INSURANCE COMPANY

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

Policy contract number

B7366

Policy instance

Insurance contract or identification number	B7366
Number of Individuals Covered	1010
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $91,935
Total amount of fees paid to insurance company	USD $28,296
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT, OPTIONAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $1,825,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $91,935
Amount paid for insurance broker fees	28296
Additional information about fees paid to insurance broker	FEES PAID
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

B7366

Policy instance

Insurance contract or identification number	B7366
Number of Individuals Covered	1136
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $99,515
Total amount of fees paid to insurance company	USD $27,808
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH DISMEMBERMENT, OPTIONAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $1,887,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $99,515
Amount paid for insurance broker fees	27808
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN OF NEW YORK, INC.

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

Policy contract number

514176, 814176,

Policy instance

Insurance contract or identification number	514176, 814176,
Number of Individuals Covered	30
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN EMPIRE STATE

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

Policy contract number

001, 002, C02,

Policy instance

Insurance contract or identification number	001, 002, C02,
Number of Individuals Covered	2679
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,723
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $149,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,723
Insurance broker organization code?	3
Insurance broker name	HM LIFE INSURANCE COMPANY OF NY

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

Policy contract number

001,002,C02,COB

Policy instance

Insurance contract or identification number	001,002,C02,COB
Number of Individuals Covered	2756
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,852
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $135,960
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

B714,B7366

Policy instance

Insurance contract or identification number	B714,B7366
Number of Individuals Covered	1173
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $96,649
Total amount of fees paid to insurance company	USD $25,676
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT, OPTIONAL LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,820,389
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

B714,B7366

Policy instance

Insurance contract or identification number	B714,B7366
Number of Individuals Covered	1138
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $79,125
Total amount of fees paid to insurance company	USD $24,024
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,532,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

001,002,C02,COB

Policy instance

Insurance contract or identification number	001,002,C02,COB
Number of Individuals Covered	2561
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,852
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $125,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SRC, INC.
Employer identification number (EIN):	150589832
NAIC Classification:	541700

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1996-10-22
Company Identification Number:	2077004
Legal Registered Office Address:	7502 ROUND POND ROAD Onondaga N. SYRACUSE United States of America (USA) 13212