401k Plan data: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN plan

UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 401k Plan overview

Plan Name	UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN
Plan identification number	527

UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT 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

UPSTATE NIAGARA COOPERATIVE, INC. has sponsored the creation of one or more 401k plans.

Company Name: UPSTATE NIAGARA COOPERATIVE, INC.

Employer identification number (EIN): 160845625

NAIC Classification: 112120
NAIC Description: Dairy Cattle and Milk Production

Additional information about UPSTATE NIAGARA COOPERATIVE, INC.

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1960-12-27

Company Identification Number: 134073

Legal Registered Office Address: PO BOX 268
368 PLEASANT VIEW DRIVE
LANCASTER
United States of America (USA)
14086

More information about UPSTATE NIAGARA COOPERATIVE, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
527 2022-01-01 MICHAEL J. FUCHS 2023-07-17
527 2021-01-01
527 2020-01-01
527 2019-01-01
527 2018-01-01
527 2017-01-01 MICHAEL FUCHS 2023-08-11
527 2016-01-01 MICHAEL PATTERSON
527 2015-01-01 EDWARD LUONGO
527 2014-01-01 EDWARD LUONGO
527 2013-01-01 EDWARD LUONGO
527 2012-01-01 EDWARD LUONGO
527 2012-01-01 EDWARD LUONGO
527 2011-01-01 EDWARD LUONGO
527 2010-01-01 EDWARD LUONGO
527 2009-01-01 EDWARD LUONGO
527 2009-01-01 EDWARD LUONGO
527 2009-01-01 EDWARD LUONGO

Plan Statistics for UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN

401k plan membership statisitcs for UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN

Measure Date Value
2022: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 1,336
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 1,886
Number of retired or separated participants receiving benefits 2022-01-01 2
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 1,888
Number of employers contributing to the scheme 2022-01-01 0
2021: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 1,334
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 1,331
Number of retired or separated participants receiving benefits 2021-01-01 5
Total of all active and inactive participants 2021-01-01 1,336
Total participants 2021-01-01 1,336
2020: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 1,322
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 1,319
Number of retired or separated participants receiving benefits 2020-01-01 15
Total of all active and inactive participants 2020-01-01 1,334
Total participants 2020-01-01 1,334
2019: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,170
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 1,308
Number of retired or separated participants receiving benefits 2019-01-01 14
Total of all active and inactive participants 2019-01-01 1,322
Total participants 2019-01-01 1,322
2018: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 894
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 1,153
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 1,170
Total participants 2018-01-01 1,170
2017: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 899
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 877
Number of retired or separated participants receiving benefits 2017-01-01 17
Total of all active and inactive participants 2017-01-01 894
Total participants 2017-01-01 894
2016: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 830
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 881
Number of retired or separated participants receiving benefits 2016-01-01 18
Total of all active and inactive participants 2016-01-01 899
Total participants 2016-01-01 899
2015: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 692
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 820
Number of retired or separated participants receiving benefits 2015-01-01 10
Total of all active and inactive participants 2015-01-01 830
Total participants 2015-01-01 830
2014: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 702
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 692
Number of retired or separated participants receiving benefits 2014-01-01 12
Total of all active and inactive participants 2014-01-01 704
Total participants 2014-01-01 704
2013: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 737
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 688
Number of retired or separated participants receiving benefits 2013-01-01 14
Total of all active and inactive participants 2013-01-01 702
Total participants 2013-01-01 702
2012: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 736
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 720
Number of retired or separated participants receiving benefits 2012-01-01 17
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 737
Total participants 2012-01-01 737
2011: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 723
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 716
Number of retired or separated participants receiving benefits 2011-01-01 20
Total of all active and inactive participants 2011-01-01 736
Total participants 2011-01-01 736
2010: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 698
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 704
Number of retired or separated participants receiving benefits 2010-01-01 19
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 723
Total participants 2010-01-01 723
2009: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 668
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 671
Number of retired or separated participants receiving benefits 2009-01-01 27
Total of all active and inactive participants 2009-01-01 698
Total participants 2009-01-01 698

Measure	Date	Value
2022: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	1,336
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	1,886
Number of retired or separated participants receiving benefits	2022-01-01	2
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	1,888
Number of employers contributing to the scheme	2022-01-01	0
2021: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	1,334
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	1,331
Number of retired or separated participants receiving benefits	2021-01-01	5
Total of all active and inactive participants	2021-01-01	1,336
Total participants	2021-01-01	1,336
2020: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	1,322
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,319
Number of retired or separated participants receiving benefits	2020-01-01	15
Total of all active and inactive participants	2020-01-01	1,334
Total participants	2020-01-01	1,334
2019: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,170
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	1,308
Number of retired or separated participants receiving benefits	2019-01-01	14
Total of all active and inactive participants	2019-01-01	1,322
Total participants	2019-01-01	1,322
2018: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	894
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,153
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	1,170
Total participants	2018-01-01	1,170
2017: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	899
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	877
Number of retired or separated participants receiving benefits	2017-01-01	17
Total of all active and inactive participants	2017-01-01	894
Total participants	2017-01-01	894
2016: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	830
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	881
Number of retired or separated participants receiving benefits	2016-01-01	18
Total of all active and inactive participants	2016-01-01	899
Total participants	2016-01-01	899
2015: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	692
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	820
Number of retired or separated participants receiving benefits	2015-01-01	10
Total of all active and inactive participants	2015-01-01	830
Total participants	2015-01-01	830
2014: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	702
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	692
Number of retired or separated participants receiving benefits	2014-01-01	12
Total of all active and inactive participants	2014-01-01	704
Total participants	2014-01-01	704
2013: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	737
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	688
Number of retired or separated participants receiving benefits	2013-01-01	14
Total of all active and inactive participants	2013-01-01	702
Total participants	2013-01-01	702
2012: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	736
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	720
Number of retired or separated participants receiving benefits	2012-01-01	17
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	737
Total participants	2012-01-01	737
2011: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	723
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	716
Number of retired or separated participants receiving benefits	2011-01-01	20
Total of all active and inactive participants	2011-01-01	736
Total participants	2011-01-01	736
2010: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	698
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	704
Number of retired or separated participants receiving benefits	2010-01-01	19
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	723
Total participants	2010-01-01	723
2009: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	668
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	671
Number of retired or separated participants receiving benefits	2009-01-01	27
Total of all active and inactive participants	2009-01-01	698
Total participants	2009-01-01	698

Form 5500 Responses for UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN

2022: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan 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: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan 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: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan 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: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
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: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan 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: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
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: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT 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 – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: UPSTATE FARMS COOPERATIVE INC. GROUP BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	Plan funding arrangement – Insurance	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 – General assets of the sponsor	Yes

Insurance Providers Used on plan

FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )

Policy contract number

10056541001

Policy instance

Insurance contract or identification number	10056541001
Number of Individuals Covered	1161
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,613
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,613
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

ESI (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

5551

Policy instance

Insurance contract or identification number	5551
Number of Individuals Covered	1886
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $34,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

11449731

Policy instance

Insurance contract or identification number	11449731
Number of Individuals Covered	2082
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $176,989
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $176,989
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

585347

Policy instance

Insurance contract or identification number	585347
Number of Individuals Covered	1087
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $20,375
Total amount of fees paid to insurance company	USD $20,281
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $365,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,375
Amount paid for insurance broker fees	20281
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY008440

Policy instance

Insurance contract or identification number	ABY008440
Number of Individuals Covered	714
Insurance policy start date	2021-04-08
Insurance policy end date	2022-04-07
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
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

00585347

Policy instance

Insurance contract or identification number	00585347
Number of Individuals Covered	1090
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $19,548
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
Commission paid to Insurance Broker	USD $19,548
Insurance broker organization code?	3

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

11449731

Policy instance

Insurance contract or identification number	11449731
Number of Individuals Covered	400
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $33,167
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEALTH & PHARM RX
Commission paid to Insurance Broker	USD $33,167
Insurance broker organization code?	3

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

906913

Policy instance

Insurance contract or identification number	906913
Number of Individuals Covered	1331
Insurance policy start date	2021-01-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $3,345
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Commission paid to Insurance Broker	USD $3,345
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

223177

Policy instance

Insurance contract or identification number	223177
Number of Individuals Covered	141
Insurance policy start date	2021-01-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $1,638
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
Commission paid to Insurance Broker	USD $1,638
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY008440

Policy instance

Insurance contract or identification number	ABY008440
Number of Individuals Covered	345
Insurance policy start date	2021-04-08
Insurance policy end date	2022-04-08
Other welfare benefits provided	ACCIDENTAL DEATH/TRAVEL

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

Policy contract number

00569548

Policy instance

Insurance contract or identification number	00569548
Number of Individuals Covered	438
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $391
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $391
Insurance broker organization code?	3

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

Policy contract number

00942230

Policy instance

Insurance contract or identification number	00942230
Number of Individuals Covered	218
Insurance policy start date	2021-05-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,732
Temporary Disability Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $1,732
Insurance broker organization code?	3

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

Policy contract number

00942285

Policy instance

Insurance contract or identification number	00942285
Number of Individuals Covered	922
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,669
Temporary Disability Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $4,669
Insurance broker organization code?	3

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

11444155

Policy instance

Insurance contract or identification number	11444155
Number of Individuals Covered	604
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $54,213
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEALTH & PHARM RX
Commission paid to Insurance Broker	USD $54,213
Insurance broker organization code?	3

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

906914

Policy instance

Insurance contract or identification number	906914
Number of Individuals Covered	637
Insurance policy start date	2021-01-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $2,223
Other welfare benefits provided	NYD & FAMILY LEAVE
Commission paid to Insurance Broker	USD $1,185
Insurance broker organization code?	3

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

000010220747000

Policy instance

Insurance contract or identification number	000010220747000
Number of Individuals Covered	28
Insurance policy start date	2021-01-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $123
Long Term Disability Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $123
Insurance broker organization code?	3

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

11444155

Policy instance

Insurance contract or identification number	11444155
Number of Individuals Covered	588
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $56,956
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEALTH & PHARM RX
Commission paid to Insurance Broker	USD $54,055
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

223177

Policy instance

Insurance contract or identification number	223177
Number of Individuals Covered	139
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,598
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
Commission paid to Insurance Broker	USD $6,013
Insurance broker organization code?	3

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

906913

Policy instance

Insurance contract or identification number	906913
Number of Individuals Covered	1319
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

906914

Policy instance

Insurance contract or identification number	906914
Number of Individuals Covered	632
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,466
Other welfare benefits provided	NYD & FAMILY LEAVE
Commission paid to Insurance Broker	USD $4,466
Insurance broker organization code?	3

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

000010220747000

Policy instance

Insurance contract or identification number	000010220747000
Number of Individuals Covered	28
Insurance policy start date	2020-10-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $429
Long Term Disability Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $56
Insurance broker organization code?	3

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

Policy contract number

00569548

Policy instance

Insurance contract or identification number	00569548
Number of Individuals Covered	291
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY008440

Policy instance

Insurance contract or identification number	ABY008440
Number of Individuals Covered	299
Insurance policy start date	2020-04-08
Insurance policy end date	2021-04-08
Total amount of commissions paid to insurance broker	USD $203
Other welfare benefits provided	ACCIDENTAL DEATH/TRAVEL
Commission paid to Insurance Broker	USD $203
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

000010220747000

Policy instance

Insurance contract or identification number	000010220747000
Number of Individuals Covered	31
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $729
Long Term Disability Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $729
Insurance broker organization code?	3

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

11444155

Policy instance

Insurance contract or identification number	11444155
Number of Individuals Covered	601
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $39,395
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEALTH & PHARM RX
Commission paid to Insurance Broker	USD $39,395

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

906914

Policy instance

Insurance contract or identification number	906914
Number of Individuals Covered	649
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,877
Other welfare benefits provided	NYD & FAMILY LEAVE
Commission paid to Insurance Broker	USD $1,877
Insurance broker organization code?	3

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

906913

Policy instance

Insurance contract or identification number	906913
Number of Individuals Covered	1308
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Commission paid to Insurance Broker	USD $0

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

223177

Policy instance

Insurance contract or identification number	223177
Number of Individuals Covered	147
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,391
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
Commission paid to Insurance Broker	USD $6,391
Insurance broker organization code?	3

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413567

Policy instance

Insurance contract or identification number	00413567
Number of Individuals Covered	464
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $46,778
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
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 $46,778
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY008440

Policy instance

Insurance contract or identification number	ABY008440
Number of Individuals Covered	299
Insurance policy start date	2017-04-08
Insurance policy end date	2018-04-08
Total amount of commissions paid to insurance broker	USD $203
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	ACCIDENTAL DEATH
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 $203
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

223177

Policy instance

Insurance contract or identification number	223177
Number of Individuals Covered	148
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,977
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
Commission paid to Insurance Broker	USD $5,977

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00400316

Policy instance

Insurance contract or identification number	00400316
Number of Individuals Covered	4
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	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
Insurance broker organization code?	3

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00400317

Policy instance

Insurance contract or identification number	00400317
Number of Individuals Covered	9
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	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
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

223178

Policy instance

Insurance contract or identification number	223178
Number of Individuals Covered	63
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $958
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	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 $958

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413568

Policy instance

Insurance contract or identification number	00413568
Number of Individuals Covered	55
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,174
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	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 $6,174
Insurance broker organization code?	3

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	253
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	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	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Insurance broker organization code?	3

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	1062
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,127
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
Commission paid to Insurance Broker	USD $6,127
Insurance broker organization code?	3

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	215
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,837
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	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Commission paid to Insurance Broker	USD $4,837
Insurance broker organization code?	3

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

117613

Policy instance

Insurance contract or identification number	117613
Number of Individuals Covered	284
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,312
Total amount of fees paid to insurance company	USD $23
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
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $3,312
Amount paid for insurance broker fees	23

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413568

Policy instance

Insurance contract or identification number	00413568
Number of Individuals Covered	45
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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	BENEFITS ADVANTAGE, INC.

GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )

Policy contract number

117613

Policy instance

Insurance contract or identification number	117613
Number of Individuals Covered	304
Insurance policy start date	2015-07-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $20,692
Total amount of fees paid to insurance company	USD $3
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,692
Amount paid for insurance broker fees	3
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	FIRST NATIONAL INS AGENCY

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

223178

Policy instance

Insurance contract or identification number	223178
Number of Individuals Covered	77
Insurance policy start date	2015-07-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,064
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,064
Insurance broker name	FIRST NATIONAL INSURANCE AGENCY LLC

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	246
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Insurance broker organization code?	3
Insurance broker name	BENEFITS ADVANTAGE INC.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	691
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,880
Life Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $7,880
Insurance broker organization code?	3
Insurance broker name	BENEFITS ADVANTAGE INC.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	205
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,570
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,570
Insurance broker organization code?	3
Insurance broker name	BENEFITS ADVANTAGE INC.

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY008440

Policy instance

Insurance contract or identification number	ABY008440
Other welfare benefits provided	ACCIDENTAL DEATH
Insurance broker organization code?	3
Insurance broker name	E.T. CLAUSS & COMPANY INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413567

Policy instance

Insurance contract or identification number	00413567
Number of Individuals Covered	410
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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	BENEFITS ADVANTAGE, INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00400317

Policy instance

Insurance contract or identification number	00400317
Number of Individuals Covered	5
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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	BENEFITS ADVANTAGE, INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00400316

Policy instance

Insurance contract or identification number	00400316
Number of Individuals Covered	5
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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	BENEFITS ADVANTAGE, INC.

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

223177

Policy instance

Insurance contract or identification number	223177
Number of Individuals Covered	124
Insurance policy start date	2015-07-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,196
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,031
Insurance broker name	FIRST NATIONAL INSURANCE AGENCY LLC

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413568

Policy instance

Insurance contract or identification number	00413568
Number of Individuals Covered	46
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
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	BENEFITS ADVANTAGE, INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00400316

Policy instance

Insurance contract or identification number	00400316
Number of Individuals Covered	7
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,334
Insurance broker organization code?	3
Insurance broker name	BENEFITS ADVANTAGE, INC.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	245
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
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	BENEFITS ADVANTAGE INC.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	200
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,654
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,654
Insurance broker organization code?	3
Insurance broker name	BENEFITS ADVANTAGE INC.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	692
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,741
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,741
Insurance broker organization code?	3
Insurance broker name	BENEFITS ADVANTAGE INC.

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY008440

Policy instance

Insurance contract or identification number	ABY008440
Number of Individuals Covered	275
Insurance policy start date	2014-04-08
Insurance policy end date	2015-04-08
Total amount of commissions paid to insurance broker	USD $203
Other welfare benefits provided	ACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $203
Insurance broker organization code?	3
Insurance broker name	E.T. CLAUSS & COMPANY INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00400317

Policy instance

Insurance contract or identification number	00400317
Number of Individuals Covered	3
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $280
Insurance broker organization code?	3
Insurance broker name	BENEFITS ADVANTAGE, INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413567

Policy instance

Insurance contract or identification number	00413567
Number of Individuals Covered	420
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
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	BENEFITS ADVANTAGE, INC.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	245
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
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	BENEFITS ADVANTAGE INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413567

Policy instance

Insurance contract or identification number	00413567
Number of Individuals Covered	438
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
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	BENEFITS ADVANTAGE, INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00400316

Policy instance

Insurance contract or identification number	00400316
Number of Individuals Covered	7
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,098
Insurance broker organization code?	3
Insurance broker name	BENEFITS ADVANTAGE, INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00400317

Policy instance

Insurance contract or identification number	00400317
Number of Individuals Covered	3
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $180
Insurance broker organization code?	3
Insurance broker name	BENEFITS ADVANTAGE, INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413568

Policy instance

Insurance contract or identification number	00413568
Number of Individuals Covered	35
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
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	BENEFITS ADVANTAGE, INC.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	688
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,740
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,740
Insurance broker organization code?	3
Insurance broker name	BENEFITS ADVANTAGE INC.

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY008440

Policy instance

Insurance contract or identification number	ABY008440
Number of Individuals Covered	264
Insurance policy start date	2013-04-01
Insurance policy end date	2014-04-01
Other welfare benefits provided	ACCIDENTAL DEATH
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	E.T. CLAUSS & COMPANY INC.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	205
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,654
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,654
Insurance broker organization code?	3
Insurance broker name	BENEFITS ADVANTAGE INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00400316

Policy instance

Insurance contract or identification number	00400316
Number of Individuals Covered	6
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $720
Insurance broker name	BENEFITS ADVANTAGE, INC.

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY008440

Policy instance

Insurance contract or identification number	ABY008440
Number of Individuals Covered	264
Insurance policy start date	2012-04-01
Insurance policy end date	2013-04-01
Total amount of commissions paid to insurance broker	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413568

Policy instance

Insurance contract or identification number	00413568
Number of Individuals Covered	34
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413568

Policy instance

Insurance contract or identification number	00413568
Number of Individuals Covered	34
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	BENEFITS ADVANTAGE, INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413567

Policy instance

Insurance contract or identification number	00413567
Number of Individuals Covered	453
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	BENEFITS ADVANTAGE, INC.

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY008440

Policy instance

Insurance contract or identification number	ABY008440
Number of Individuals Covered	264
Insurance policy start date	2012-04-01
Insurance policy end date	2013-04-01
Total amount of commissions paid to insurance broker	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
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
Insurance broker name	E.T. CLAUSS & COMPANY INC.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	213
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,644
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Life Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $4,720
Insurance broker name	BENEFITS ADVANTAGE INC.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	255
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Total amount of commissions paid to insurance broker	USD $4,644
Long Term Disability Insurance Welfare Benefit	Yes
Commission paid to Insurance Broker	USD $4,644
Insurance broker name	BENEFITS ADVANTAGE INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00413567

Policy instance

Insurance contract or identification number	00413567
Number of Individuals Covered	453
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

30407M

Policy instance

Insurance contract or identification number	30407M
Number of Individuals Covered	3
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00400317

Policy instance

Insurance contract or identification number	00400317
Number of Individuals Covered	3
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $180
Insurance broker name	BENEFITS ADVANTAGE, INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00400316

Policy instance

Insurance contract or identification number	00400316
Number of Individuals Covered	6
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	708
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,720
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

30407M

Policy instance

Insurance contract or identification number	30407M
Number of Individuals Covered	3
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	BENEFITS ADVANTAGE, INC.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	255
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	BENEFITS ADVANTAGE INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00995204

Policy instance

Insurance contract or identification number	00995204
Number of Individuals Covered	110
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Other welfare benefits provided	POS
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

2862 543

Policy instance

Insurance contract or identification number	2862 543
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
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

10113 01

Policy instance

Insurance contract or identification number	10113 01
Number of Individuals Covered	3
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $26,975
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

2862 002

Policy instance

Insurance contract or identification number	2862 002
Number of Individuals Covered	38
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

30407M

Policy instance

Insurance contract or identification number	30407M
Number of Individuals Covered	8
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

2862 655

Policy instance

Insurance contract or identification number	2862 655
Number of Individuals Covered	2
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

2862 658

Policy instance

Insurance contract or identification number	2862 658
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY008440

Policy instance

Insurance contract or identification number	ABY008440
Number of Individuals Covered	264
Insurance policy start date	2011-04-08
Insurance policy end date	2012-04-08
Total amount of commissions paid to insurance broker	USD $203
Other welfare benefits provided	ACCIDENTAL DEATH
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

AD32A006

Policy instance

Insurance contract or identification number	AD32A006
Number of Individuals Covered	9
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,091
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

2862 509

Policy instance

Insurance contract or identification number	2862 509
Number of Individuals Covered	4
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	256
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
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

32017 001

Policy instance

Insurance contract or identification number	32017 001
Number of Individuals Covered	36
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $32,179
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

32017 002

Policy instance

Insurance contract or identification number	32017 002
Number of Individuals Covered	23
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

31404H

Policy instance

Insurance contract or identification number	31404H
Number of Individuals Covered	160
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	213
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,642
Long Term Disability 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

32017 401

Policy instance

Insurance contract or identification number	32017 401
Number of Individuals Covered	2
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

2862 652

Policy instance

Insurance contract or identification number	2862 652
Number of Individuals Covered	34
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	716
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,688
Life 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

2862 657

Policy instance

Insurance contract or identification number	2862 657
Number of Individuals Covered	5
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

30407M

Policy instance

Insurance contract or identification number	30407M
Number of Individuals Covered	9
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	704
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $9,164
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,164
Insurance broker name	BENEFITS ADVANTAGE INC.

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

Policy contract number

2862 002

Policy instance

Insurance contract or identification number	2862 002
Number of Individuals Covered	221
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $691,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	AGRI-BUSINESS BROKERAGE CORP.

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

Policy contract number

10113 01

Policy instance

Insurance contract or identification number	10113 01
Number of Individuals Covered	7
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,899
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,650
Insurance broker name	BENEFITS ADVANTAGE, INC.

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY008440

Policy instance

Insurance contract or identification number	ABY008440
Number of Individuals Covered	264
Insurance policy start date	2010-04-08
Insurance policy end date	2011-04-08
Total amount of commissions paid to insurance broker	USD $87
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $87
Insurance broker name	E.T. CLAUSS & COMPANY INC.

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

Policy contract number

2862 658

Policy instance

Insurance contract or identification number	2862 658
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	AGRI-BUSINESS BROKERAGE CORP.

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

Policy contract number

32017 001

Policy instance

Insurance contract or identification number	32017 001
Number of Individuals Covered	92
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $11,537
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $191,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,537
Insurance broker name	BENEFITS ADVANTAGE, INC.

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

Policy contract number

32017 002

Policy instance

Insurance contract or identification number	32017 002
Number of Individuals Covered	55
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $128,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	BENEFITS ADVANTAGE, INC.

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

Policy contract number

2862 005

Policy instance

Insurance contract or identification number	2862 005
Number of Individuals Covered	0
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $127,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	AGRI-BUSINESS BROKERAGE CORP.

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	204
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

677634G

Policy instance

Insurance contract or identification number	677634G
Number of Individuals Covered	247
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH/DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $5,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )

Policy contract number

X0181

Policy instance

Insurance contract or identification number	X0181
Number of Individuals Covered	8
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $86,936
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

AD32R001

Policy instance

Insurance contract or identification number	AD32R001
Number of Individuals Covered	2
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	BENEFITS ADVANTAGE, INC.

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00995204

Policy instance

Insurance contract or identification number	00995204
Number of Individuals Covered	120
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $608,993
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

2862 001

Policy instance

Insurance contract or identification number	2862 001
Number of Individuals Covered	0
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $56,504
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $188,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,779
Insurance broker name	AGRI-BUSINESS BROKERAGE CORP.

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

Policy contract number

AD32A006

Policy instance

Insurance contract or identification number	AD32A006
Number of Individuals Covered	20
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,127
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP TRAVEL/ACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,127
Insurance broker name	BENEFITS ADVANTAGE, INC.

INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 )

Policy contract number

31404H

Policy instance

Insurance contract or identification number	31404H
Number of Individuals Covered	145
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $779,509
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

AD32R010

Policy instance

Insurance contract or identification number	AD32R010
Number of Individuals Covered	0
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	BENEFITS ADVANTAGE, INC.

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

Policy contract number

2862 652

Policy instance

Insurance contract or identification number	2862 652
Number of Individuals Covered	7
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $102,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	AGRI-BUSINESS BROKERAGE CORP.

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

Policy contract number

AD32R009

Policy instance

Insurance contract or identification number	AD32R009
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	BENEFITS ADVANTAGE, INC.

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

Policy contract number

2862 657

Policy instance

Insurance contract or identification number	2862 657
Number of Individuals Covered	4
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	AGRI-BUSINESS BROKERAGE CORP.

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Company Name:	UPSTATE NIAGARA COOPERATIVE, INC.
Employer identification number (EIN):	160845625
NAIC Classification:	112120
NAIC Description:	Dairy Cattle and Milk Production

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1960-12-27
Company Identification Number:	134073
Legal Registered Office Address:	PO BOX 268 368 PLEASANT VIEW DRIVE LANCASTER United States of America (USA) 14086

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
527	2022-01-01	MICHAEL J. FUCHS	2023-07-17
527	2021-01-01
527	2020-01-01
527	2019-01-01
527	2018-01-01
527	2017-01-01	MICHAEL FUCHS	2023-08-11
527	2016-01-01	MICHAEL PATTERSON
527	2015-01-01	EDWARD LUONGO
527	2014-01-01	EDWARD LUONGO
527	2013-01-01	EDWARD LUONGO
527	2012-01-01	EDWARD LUONGO
527	2012-01-01	EDWARD LUONGO
527	2011-01-01	EDWARD LUONGO
527	2010-01-01	EDWARD LUONGO
527	2009-01-01	EDWARD LUONGO
527	2009-01-01	EDWARD LUONGO
527	2009-01-01	EDWARD LUONGO