ROCHESTER AREA CONSTRUCTION AND MATERIALS HEALTH AND WELFARE has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND
401k plan membership statisitcs for ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND
| Measure | Date | Value |
|---|
| 2023 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2023 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2023-07-31 | $165,338 |
| Total unrealized appreciation/depreciation of assets | 2023-07-31 | $165,338 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2023-07-31 | $189,912 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2023-07-31 | $159,511 |
| Total income from all sources (including contributions) | 2023-07-31 | $6,989,214 |
| Total loss/gain on sale of assets | 2023-07-31 | $43,022 |
| Total of all expenses incurred | 2023-07-31 | $6,782,544 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2023-07-31 | $6,351,373 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2023-07-31 | $6,463,512 |
| Value of total assets at end of year | 2023-07-31 | $7,204,723 |
| Value of total assets at beginning of year | 2023-07-31 | $6,967,652 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2023-07-31 | $431,171 |
| Total interest from all sources | 2023-07-31 | $6,318 |
| Total dividends received (eg from common stock, registered investment company shares) | 2023-07-31 | $240,894 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2023-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2023-07-31 | $201,188 |
| Administrative expenses professional fees incurred | 2023-07-31 | $144,961 |
| Assets. Corporate prefeered stocks other than exployer securities at end of year | 2023-07-31 | $548,901 |
| Was this plan covered by a fidelity bond | 2023-07-31 | Yes |
| Value of fidelity bond cover | 2023-07-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2023-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2023-07-31 | No |
| Contributions received from participants | 2023-07-31 | $661,722 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2023-07-31 | $24,776 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2023-07-31 | $18,771 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2023-07-31 | $144,291 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2023-07-31 | $110,413 |
| Other income not declared elsewhere | 2023-07-31 | $70,130 |
| Administrative expenses (other) incurred | 2023-07-31 | $233,961 |
| Liabilities. Value of operating payables at end of year | 2023-07-31 | $45,621 |
| Liabilities. Value of operating payables at beginning of year | 2023-07-31 | $49,098 |
| Total non interest bearing cash at end of year | 2023-07-31 | $4,242 |
| Total non interest bearing cash at beginning of year | 2023-07-31 | $5,003 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2023-07-31 | No |
| Value of net income/loss | 2023-07-31 | $206,670 |
| Value of net assets at end of year (total assets less liabilities) | 2023-07-31 | $7,014,811 |
| Value of net assets at beginning of year (total assets less liabilities) | 2023-07-31 | $6,808,141 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2023-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2023-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2023-07-31 | No |
| Investment advisory and management fees | 2023-07-31 | $52,249 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2023-07-31 | $5,504,250 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2023-07-31 | $5,000,958 |
| Value of interest in pooled separate accounts at end of year | 2023-07-31 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2023-07-31 | $264,125 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2023-07-31 | $278,605 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2023-07-31 | $278,605 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2023-07-31 | $6,318 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2023-07-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2023-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2023-07-31 | No |
| Contributions received in cash from employer | 2023-07-31 | $5,801,790 |
| Employer contributions (assets) at end of year | 2023-07-31 | $79,979 |
| Employer contributions (assets) at beginning of year | 2023-07-31 | $92,476 |
| Income. Dividends from preferred stock | 2023-07-31 | $34,857 |
| Income. Dividends from common stock | 2023-07-31 | $4,849 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2023-07-31 | $6,351,373 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2023-07-31 | $590,730 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2023-07-31 | $806,943 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2023-07-31 | No |
| Assets. Corporate common stocks other than exployer securities at end of year | 2023-07-31 | $615,417 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2023-07-31 | $163,033 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2023-07-31 | $174,166 |
| Did the plan have assets held for investment | 2023-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2023-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2023-07-31 | No |
| Aggregate proceeds on sale of assets | 2023-07-31 | $5,970,842 |
| Aggregate carrying amount (costs) on sale of assets | 2023-07-31 | $5,927,820 |
| Opinion of an independent qualified public accountant for this plan | 2023-07-31 | Unqualified |
| Accountancy firm name | 2023-07-31 | STOKES, VISCA, HUCKO & BARONE, CPAS |
| Accountancy firm EIN | 2023-07-31 | 474215313 |
| 2022 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2022 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2022-07-31 | $-640,329 |
| Total unrealized appreciation/depreciation of assets | 2022-07-31 | $-640,329 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-07-31 | $159,511 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-07-31 | $223,233 |
| Total income from all sources (including contributions) | 2022-07-31 | $6,174,471 |
| Total loss/gain on sale of assets | 2022-07-31 | $-26,715 |
| Total of all expenses incurred | 2022-07-31 | $6,950,244 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-07-31 | $6,544,780 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-07-31 | $6,579,281 |
| Value of total assets at end of year | 2022-07-31 | $6,967,652 |
| Value of total assets at beginning of year | 2022-07-31 | $7,807,147 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2022-07-31 | $405,464 |
| Total interest from all sources | 2022-07-31 | $100 |
| Total dividends received (eg from common stock, registered investment company shares) | 2022-07-31 | $193,964 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2022-07-31 | $150,158 |
| Administrative expenses professional fees incurred | 2022-07-31 | $126,021 |
| Was this plan covered by a fidelity bond | 2022-07-31 | Yes |
| Value of fidelity bond cover | 2022-07-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2022-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2022-07-31 | No |
| Contributions received from participants | 2022-07-31 | $632,693 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2022-07-31 | $18,771 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2022-07-31 | $17,198 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2022-07-31 | $110,413 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2022-07-31 | $161,542 |
| Other income not declared elsewhere | 2022-07-31 | $68,170 |
| Administrative expenses (other) incurred | 2022-07-31 | $220,059 |
| Liabilities. Value of operating payables at end of year | 2022-07-31 | $49,098 |
| Liabilities. Value of operating payables at beginning of year | 2022-07-31 | $61,691 |
| Total non interest bearing cash at end of year | 2022-07-31 | $5,003 |
| Total non interest bearing cash at beginning of year | 2022-07-31 | $9,669 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-07-31 | No |
| Value of net income/loss | 2022-07-31 | $-775,773 |
| Value of net assets at end of year (total assets less liabilities) | 2022-07-31 | $6,808,141 |
| Value of net assets at beginning of year (total assets less liabilities) | 2022-07-31 | $7,583,914 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-07-31 | No |
| Investment advisory and management fees | 2022-07-31 | $59,384 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2022-07-31 | $5,000,958 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2022-07-31 | $6,075,278 |
| Value of interest in pooled separate accounts at end of year | 2022-07-31 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2022-07-31 | $278,605 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2022-07-31 | $198,437 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2022-07-31 | $198,437 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2022-07-31 | $100 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2022-07-31 | $6,228,172 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-07-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2022-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-07-31 | No |
| Contributions received in cash from employer | 2022-07-31 | $5,946,588 |
| Employer contributions (assets) at end of year | 2022-07-31 | $92,476 |
| Employer contributions (assets) at beginning of year | 2022-07-31 | $93,200 |
| Income. Dividends from preferred stock | 2022-07-31 | $39,621 |
| Income. Dividends from common stock | 2022-07-31 | $4,185 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2022-07-31 | $316,608 |
| Asset. Corporate debt instrument preferred debt at end of year | 2022-07-31 | $590,730 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2022-07-31 | $709,523 |
| Asset. Corporate debt instrument debt (other) at end of year | 2022-07-31 | $806,943 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2022-07-31 | $543,285 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2022-07-31 | No |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2022-07-31 | $174,166 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2022-07-31 | $160,557 |
| Did the plan have assets held for investment | 2022-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-07-31 | No |
| Aggregate proceeds on sale of assets | 2022-07-31 | $6,392,142 |
| Aggregate carrying amount (costs) on sale of assets | 2022-07-31 | $6,418,857 |
| Opinion of an independent qualified public accountant for this plan | 2022-07-31 | Unqualified |
| Accountancy firm name | 2022-07-31 | STOKES, VISCA, HUCKO & BARONE, CPAS |
| Accountancy firm EIN | 2022-07-31 | 474215313 |
| 2021 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2021 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2021-07-31 | $866,852 |
| Total unrealized appreciation/depreciation of assets | 2021-07-31 | $866,852 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-07-31 | $223,233 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-07-31 | $229,986 |
| Total income from all sources (including contributions) | 2021-07-31 | $8,403,670 |
| Total loss/gain on sale of assets | 2021-07-31 | $548,419 |
| Total of all expenses incurred | 2021-07-31 | $7,093,167 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-07-31 | $6,742,134 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-07-31 | $6,689,151 |
| Value of total assets at end of year | 2021-07-31 | $7,807,147 |
| Value of total assets at beginning of year | 2021-07-31 | $6,503,397 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-07-31 | $351,033 |
| Total interest from all sources | 2021-07-31 | $59 |
| Total dividends received (eg from common stock, registered investment company shares) | 2021-07-31 | $233,583 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2021-07-31 | $191,816 |
| Administrative expenses professional fees incurred | 2021-07-31 | $98,448 |
| Was this plan covered by a fidelity bond | 2021-07-31 | Yes |
| Value of fidelity bond cover | 2021-07-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2021-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-07-31 | No |
| Contributions received from participants | 2021-07-31 | $673,621 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2021-07-31 | $17,198 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2021-07-31 | $19,735 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2021-07-31 | $161,542 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2021-07-31 | $183,355 |
| Other income not declared elsewhere | 2021-07-31 | $65,606 |
| Administrative expenses (other) incurred | 2021-07-31 | $197,563 |
| Liabilities. Value of operating payables at end of year | 2021-07-31 | $61,691 |
| Liabilities. Value of operating payables at beginning of year | 2021-07-31 | $46,631 |
| Total non interest bearing cash at end of year | 2021-07-31 | $9,669 |
| Total non interest bearing cash at beginning of year | 2021-07-31 | $4,299 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-07-31 | No |
| Value of net income/loss | 2021-07-31 | $1,310,503 |
| Value of net assets at end of year (total assets less liabilities) | 2021-07-31 | $7,583,914 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-07-31 | $6,273,411 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-07-31 | No |
| Investment advisory and management fees | 2021-07-31 | $55,022 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2021-07-31 | $6,075,278 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2021-07-31 | $4,964,202 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2021-07-31 | $198,437 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2021-07-31 | $151,088 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2021-07-31 | $151,088 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2021-07-31 | $59 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-07-31 | $6,458,782 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-07-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2021-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-07-31 | No |
| Contributions received in cash from employer | 2021-07-31 | $6,015,530 |
| Employer contributions (assets) at end of year | 2021-07-31 | $93,200 |
| Employer contributions (assets) at beginning of year | 2021-07-31 | $87,579 |
| Income. Dividends from preferred stock | 2021-07-31 | $41,767 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-07-31 | $283,352 |
| Asset. Corporate debt instrument preferred debt at end of year | 2021-07-31 | $709,523 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2021-07-31 | $950,695 |
| Asset. Corporate debt instrument debt (other) at end of year | 2021-07-31 | $543,285 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2021-07-31 | $120,960 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2021-07-31 | No |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2021-07-31 | $160,557 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2021-07-31 | $204,839 |
| Did the plan have assets held for investment | 2021-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-07-31 | No |
| Aggregate proceeds on sale of assets | 2021-07-31 | $10,010,094 |
| Aggregate carrying amount (costs) on sale of assets | 2021-07-31 | $9,461,675 |
| Opinion of an independent qualified public accountant for this plan | 2021-07-31 | Unqualified |
| Accountancy firm name | 2021-07-31 | SEAN HUCKO, CPA, LLC |
| Accountancy firm EIN | 2021-07-31 | 474215313 |
| 2020 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2020 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2020-07-31 | $373,538 |
| Total unrealized appreciation/depreciation of assets | 2020-07-31 | $373,538 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-07-31 | $229,986 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-07-31 | $239,645 |
| Total income from all sources (including contributions) | 2020-07-31 | $7,046,278 |
| Total loss/gain on sale of assets | 2020-07-31 | $-86,374 |
| Total of all expenses incurred | 2020-07-31 | $6,881,235 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-07-31 | $6,541,536 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-07-31 | $6,461,777 |
| Value of total assets at end of year | 2020-07-31 | $6,503,397 |
| Value of total assets at beginning of year | 2020-07-31 | $6,348,013 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-07-31 | $339,699 |
| Total interest from all sources | 2020-07-31 | $2,853 |
| Total dividends received (eg from common stock, registered investment company shares) | 2020-07-31 | $229,162 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2020-07-31 | $177,376 |
| Administrative expenses professional fees incurred | 2020-07-31 | $84,695 |
| Was this plan covered by a fidelity bond | 2020-07-31 | Yes |
| Value of fidelity bond cover | 2020-07-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2020-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-07-31 | No |
| Contributions received from participants | 2020-07-31 | $732,188 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2020-07-31 | $19,735 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2020-07-31 | $20,532 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2020-07-31 | $183,355 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2020-07-31 | $181,545 |
| Other income not declared elsewhere | 2020-07-31 | $65,322 |
| Administrative expenses (other) incurred | 2020-07-31 | $205,906 |
| Liabilities. Value of operating payables at end of year | 2020-07-31 | $46,631 |
| Liabilities. Value of operating payables at beginning of year | 2020-07-31 | $58,100 |
| Total non interest bearing cash at end of year | 2020-07-31 | $4,299 |
| Total non interest bearing cash at beginning of year | 2020-07-31 | $4,298 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-07-31 | No |
| Value of net income/loss | 2020-07-31 | $165,043 |
| Value of net assets at end of year (total assets less liabilities) | 2020-07-31 | $6,273,411 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-07-31 | $6,108,368 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-07-31 | No |
| Investment advisory and management fees | 2020-07-31 | $49,098 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2020-07-31 | $4,964,202 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2020-07-31 | $4,223,328 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2020-07-31 | $151,088 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2020-07-31 | $369,066 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2020-07-31 | $369,066 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2020-07-31 | $2,853 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-07-31 | $6,220,283 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-07-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2020-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-07-31 | No |
| Contributions received in cash from employer | 2020-07-31 | $5,729,589 |
| Employer contributions (assets) at end of year | 2020-07-31 | $87,579 |
| Employer contributions (assets) at beginning of year | 2020-07-31 | $87,324 |
| Income. Dividends from preferred stock | 2020-07-31 | $51,786 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2020-07-31 | $321,253 |
| Asset. Corporate debt instrument preferred debt at end of year | 2020-07-31 | $950,695 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2020-07-31 | $832,464 |
| Asset. Corporate debt instrument debt (other) at end of year | 2020-07-31 | $120,960 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2020-07-31 | $600,680 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2020-07-31 | No |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2020-07-31 | $204,839 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2020-07-31 | $210,321 |
| Did the plan have assets held for investment | 2020-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-07-31 | No |
| Aggregate proceeds on sale of assets | 2020-07-31 | $8,356,052 |
| Aggregate carrying amount (costs) on sale of assets | 2020-07-31 | $8,442,426 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2020-07-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2020-07-31 | Unqualified |
| Accountancy firm name | 2020-07-31 | SEAN HUCKO CPA LLC |
| Accountancy firm EIN | 2020-07-31 | 474215313 |
| 2018 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2018 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2018-07-31 | $144,667 |
| Total unrealized appreciation/depreciation of assets | 2018-07-31 | $144,667 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-07-31 | $213,095 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-07-31 | $205,918 |
| Total income from all sources (including contributions) | 2018-07-31 | $6,127,110 |
| Total loss/gain on sale of assets | 2018-07-31 | $47,876 |
| Total of all expenses incurred | 2018-07-31 | $6,088,571 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-07-31 | $5,809,898 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-07-31 | $5,673,994 |
| Value of total assets at end of year | 2018-07-31 | $6,127,975 |
| Value of total assets at beginning of year | 2018-07-31 | $6,082,259 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-07-31 | $278,673 |
| Total interest from all sources | 2018-07-31 | $2,942 |
| Total dividends received (eg from common stock, registered investment company shares) | 2018-07-31 | $203,696 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2018-07-31 | $148,512 |
| Administrative expenses professional fees incurred | 2018-07-31 | $57,869 |
| Was this plan covered by a fidelity bond | 2018-07-31 | Yes |
| Value of fidelity bond cover | 2018-07-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2018-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2018-07-31 | No |
| Contributions received from participants | 2018-07-31 | $905,675 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2018-07-31 | $12,795 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2018-07-31 | $13,325 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2018-07-31 | $138,810 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2018-07-31 | $141,569 |
| Other income not declared elsewhere | 2018-07-31 | $53,935 |
| Administrative expenses (other) incurred | 2018-07-31 | $172,354 |
| Liabilities. Value of operating payables at end of year | 2018-07-31 | $74,285 |
| Liabilities. Value of operating payables at beginning of year | 2018-07-31 | $64,349 |
| Total non interest bearing cash at end of year | 2018-07-31 | $4,298 |
| Total non interest bearing cash at beginning of year | 2018-07-31 | $20,186 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-07-31 | No |
| Value of net income/loss | 2018-07-31 | $38,539 |
| Value of net assets at end of year (total assets less liabilities) | 2018-07-31 | $5,914,880 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-07-31 | $5,876,341 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-07-31 | No |
| Investment advisory and management fees | 2018-07-31 | $48,450 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2018-07-31 | $4,105,316 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2018-07-31 | $4,418,161 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2018-07-31 | $87,736 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2018-07-31 | $108,115 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2018-07-31 | $108,115 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2018-07-31 | $2,942 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2018-07-31 | $5,454,108 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-07-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2018-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-07-31 | No |
| Contributions received in cash from employer | 2018-07-31 | $4,768,319 |
| Employer contributions (assets) at end of year | 2018-07-31 | $86,569 |
| Employer contributions (assets) at beginning of year | 2018-07-31 | $86,493 |
| Income. Dividends from preferred stock | 2018-07-31 | $55,184 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2018-07-31 | $355,790 |
| Asset. Corporate debt instrument preferred debt at end of year | 2018-07-31 | $1,136,459 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2018-07-31 | $851,803 |
| Asset. Corporate debt instrument debt (other) at end of year | 2018-07-31 | $479,497 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2018-07-31 | $343,205 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2018-07-31 | No |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2018-07-31 | $215,305 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2018-07-31 | $240,971 |
| Did the plan have assets held for investment | 2018-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-07-31 | No |
| Aggregate proceeds on sale of assets | 2018-07-31 | $4,176,148 |
| Aggregate carrying amount (costs) on sale of assets | 2018-07-31 | $4,128,272 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2018-07-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2018-07-31 | Unqualified |
| Accountancy firm name | 2018-07-31 | SEAN HUCKO, CPA, LLC |
| Accountancy firm EIN | 2018-07-31 | 474215313 |
| 2017 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2017 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2017-07-31 | $502,239 |
| Total unrealized appreciation/depreciation of assets | 2017-07-31 | $502,239 |
| Total transfer of assets to this plan | 2017-07-31 | $0 |
| Total transfer of assets from this plan | 2017-07-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-07-31 | $205,918 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-07-31 | $197,889 |
| Total income from all sources (including contributions) | 2017-07-31 | $6,063,552 |
| Total loss/gain on sale of assets | 2017-07-31 | $-86,272 |
| Total of all expenses incurred | 2017-07-31 | $5,783,781 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-07-31 | $5,488,772 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-07-31 | $5,377,265 |
| Value of total assets at end of year | 2017-07-31 | $6,082,259 |
| Value of total assets at beginning of year | 2017-07-31 | $5,794,459 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-07-31 | $295,009 |
| Total interest from all sources | 2017-07-31 | $2,135 |
| Total dividends received (eg from common stock, registered investment company shares) | 2017-07-31 | $217,190 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2017-07-31 | $217,190 |
| Administrative expenses professional fees incurred | 2017-07-31 | $72,565 |
| Assets. Corporate prefeered stocks other than exployer securities at end of year | 2017-07-31 | $851,803 |
| Assets. Corporate prefeered stocks other than exployer securities at beginning of year | 2017-07-31 | $156,938 |
| Was this plan covered by a fidelity bond | 2017-07-31 | Yes |
| Value of fidelity bond cover | 2017-07-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2017-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2017-07-31 | No |
| Contributions received from participants | 2017-07-31 | $1,010,594 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2017-07-31 | $13,325 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2017-07-31 | $13,590 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2017-07-31 | $141,569 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2017-07-31 | $138,826 |
| Other income not declared elsewhere | 2017-07-31 | $50,995 |
| Administrative expenses (other) incurred | 2017-07-31 | $176,506 |
| Liabilities. Value of operating payables at end of year | 2017-07-31 | $64,349 |
| Liabilities. Value of operating payables at beginning of year | 2017-07-31 | $59,063 |
| Total non interest bearing cash at end of year | 2017-07-31 | $20,186 |
| Total non interest bearing cash at beginning of year | 2017-07-31 | $20,878 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-07-31 | No |
| Value of net income/loss | 2017-07-31 | $279,771 |
| Value of net assets at end of year (total assets less liabilities) | 2017-07-31 | $5,876,341 |
| Value of net assets at beginning of year (total assets less liabilities) | 2017-07-31 | $5,596,570 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-07-31 | No |
| Investment advisory and management fees | 2017-07-31 | $45,938 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2017-07-31 | $4,418,161 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2017-07-31 | $4,766,664 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2017-07-31 | $108,115 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2017-07-31 | $175,934 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2017-07-31 | $175,934 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2017-07-31 | $2,135 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-07-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2017-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-07-31 | No |
| Contributions received in cash from employer | 2017-07-31 | $4,366,671 |
| Employer contributions (assets) at end of year | 2017-07-31 | $86,493 |
| Employer contributions (assets) at beginning of year | 2017-07-31 | $106,150 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2017-07-31 | $5,488,772 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2017-07-31 | No |
| Assets. Corporate common stocks other than exployer securities at end of year | 2017-07-31 | $343,205 |
| Assets. Corporate common stocks other than exployer securities at beginning of year | 2017-07-31 | $310,490 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2017-07-31 | $240,971 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2017-07-31 | $243,815 |
| Did the plan have assets held for investment | 2017-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-07-31 | No |
| Aggregate proceeds on sale of assets | 2017-07-31 | $5,522,180 |
| Aggregate carrying amount (costs) on sale of assets | 2017-07-31 | $5,608,452 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-07-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2017-07-31 | Unqualified |
| Accountancy firm name | 2017-07-31 | SEAN HUCKO, CPA, LLC |
| Accountancy firm EIN | 2017-07-31 | 474215313 |
| 2016 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2016 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2016-07-31 | $96,953 |
| Total unrealized appreciation/depreciation of assets | 2016-07-31 | $96,953 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-07-31 | $197,889 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-07-31 | $190,554 |
| Total income from all sources (including contributions) | 2016-07-31 | $5,523,708 |
| Total loss/gain on sale of assets | 2016-07-31 | $-22,610 |
| Total of all expenses incurred | 2016-07-31 | $5,423,453 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-07-31 | $5,153,230 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-07-31 | $5,140,798 |
| Value of total assets at end of year | 2016-07-31 | $5,794,459 |
| Value of total assets at beginning of year | 2016-07-31 | $5,686,869 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-07-31 | $270,223 |
| Total interest from all sources | 2016-07-31 | $236 |
| Total dividends received (eg from common stock, registered investment company shares) | 2016-07-31 | $258,030 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2016-07-31 | $258,030 |
| Administrative expenses professional fees incurred | 2016-07-31 | $44,225 |
| Was this plan covered by a fidelity bond | 2016-07-31 | Yes |
| Value of fidelity bond cover | 2016-07-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2016-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2016-07-31 | No |
| Contributions received from participants | 2016-07-31 | $1,043,493 |
| Participant contributions at end of year | 2016-07-31 | $106,150 |
| Participant contributions at beginning of year | 2016-07-31 | $91,685 |
| Assets. Other investments not covered elsewhere at beginning of year | 2016-07-31 | $224,500 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2016-07-31 | $13,590 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2016-07-31 | $11,342 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2016-07-31 | $138,826 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2016-07-31 | $137,577 |
| Other income not declared elsewhere | 2016-07-31 | $50,301 |
| Administrative expenses (other) incurred | 2016-07-31 | $182,256 |
| Liabilities. Value of operating payables at end of year | 2016-07-31 | $59,063 |
| Liabilities. Value of operating payables at beginning of year | 2016-07-31 | $52,977 |
| Total non interest bearing cash at end of year | 2016-07-31 | $20,878 |
| Total non interest bearing cash at beginning of year | 2016-07-31 | $5,944 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-07-31 | No |
| Value of net income/loss | 2016-07-31 | $100,255 |
| Value of net assets at end of year (total assets less liabilities) | 2016-07-31 | $5,596,570 |
| Value of net assets at beginning of year (total assets less liabilities) | 2016-07-31 | $5,496,315 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-07-31 | No |
| Assets. partnership/joint venture interests at end of year | 2016-07-31 | $310,490 |
| Investment advisory and management fees | 2016-07-31 | $43,742 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2016-07-31 | $4,766,664 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2016-07-31 | $5,012,001 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2016-07-31 | $175,934 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2016-07-31 | $108,619 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2016-07-31 | $108,619 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2016-07-31 | $236 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-07-31 | $4,852,128 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-07-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2016-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-07-31 | No |
| Contributions received in cash from employer | 2016-07-31 | $4,097,305 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2016-07-31 | $301,102 |
| Assets. Corporate common stocks other than exployer securities at end of year | 2016-07-31 | $156,938 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2016-07-31 | $243,815 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2016-07-31 | $232,778 |
| Did the plan have assets held for investment | 2016-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-07-31 | No |
| Aggregate proceeds on sale of assets | 2016-07-31 | $5,702,552 |
| Aggregate carrying amount (costs) on sale of assets | 2016-07-31 | $5,725,162 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2016-07-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2016-07-31 | Unqualified |
| Accountancy firm name | 2016-07-31 | SEAN HUCKO, CPA, LLC |
| Accountancy firm EIN | 2016-07-31 | 474215313 |
| 2015 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2015 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2015-07-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-07-31 | $190,554 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-07-31 | $166,898 |
| Total income from all sources (including contributions) | 2015-07-31 | $5,387,259 |
| Total loss/gain on sale of assets | 2015-07-31 | $92,134 |
| Total of all expenses incurred | 2015-07-31 | $5,347,655 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-07-31 | $5,113,002 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-07-31 | $5,076,602 |
| Value of total assets at end of year | 2015-07-31 | $5,686,869 |
| Value of total assets at beginning of year | 2015-07-31 | $5,623,609 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-07-31 | $234,653 |
| Total interest from all sources | 2015-07-31 | $214 |
| Total dividends received (eg from common stock, registered investment company shares) | 2015-07-31 | $252,112 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2015-07-31 | $252,112 |
| Administrative expenses professional fees incurred | 2015-07-31 | $35,365 |
| Was this plan covered by a fidelity bond | 2015-07-31 | Yes |
| Value of fidelity bond cover | 2015-07-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2015-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2015-07-31 | No |
| Contributions received from participants | 2015-07-31 | $1,060,489 |
| Participant contributions at end of year | 2015-07-31 | $91,685 |
| Participant contributions at beginning of year | 2015-07-31 | $112,031 |
| Assets. Other investments not covered elsewhere at end of year | 2015-07-31 | $224,500 |
| Assets. Other investments not covered elsewhere at beginning of year | 2015-07-31 | $106,000 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2015-07-31 | $11,342 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2015-07-31 | $11,332 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2015-07-31 | $137,577 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2015-07-31 | $127,777 |
| Other income not declared elsewhere | 2015-07-31 | $45,628 |
| Administrative expenses (other) incurred | 2015-07-31 | $154,289 |
| Liabilities. Value of operating payables at end of year | 2015-07-31 | $52,977 |
| Liabilities. Value of operating payables at beginning of year | 2015-07-31 | $39,121 |
| Total non interest bearing cash at end of year | 2015-07-31 | $5,944 |
| Total non interest bearing cash at beginning of year | 2015-07-31 | $17,473 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-07-31 | No |
| Value of net income/loss | 2015-07-31 | $39,604 |
| Value of net assets at end of year (total assets less liabilities) | 2015-07-31 | $5,496,315 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-07-31 | $5,456,711 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-07-31 | No |
| Investment advisory and management fees | 2015-07-31 | $44,999 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2015-07-31 | $5,012,001 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2015-07-31 | $5,085,731 |
| Income. Interest from US Government securities | 2015-07-31 | $123 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2015-07-31 | $108,619 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2015-07-31 | $56,412 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2015-07-31 | $56,412 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2015-07-31 | $91 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-07-31 | $4,863,119 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2015-07-31 | $-79,431 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-07-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2015-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-07-31 | No |
| Contributions received in cash from employer | 2015-07-31 | $4,016,113 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-07-31 | $249,883 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2015-07-31 | $232,778 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2015-07-31 | $234,630 |
| Did the plan have assets held for investment | 2015-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-07-31 | No |
| Aggregate proceeds on sale of assets | 2015-07-31 | $4,420,318 |
| Aggregate carrying amount (costs) on sale of assets | 2015-07-31 | $4,328,184 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-07-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2015-07-31 | Unqualified |
| Accountancy firm name | 2015-07-31 | GARY G. KRAUSS, CPA, P.C. |
| Accountancy firm EIN | 2015-07-31 | 161271514 |
| 2014 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2014 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2014-07-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-07-31 | $166,898 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-07-31 | $58,007 |
| Total income from all sources (including contributions) | 2014-07-31 | $5,099,467 |
| Total loss/gain on sale of assets | 2014-07-31 | $172,478 |
| Total of all expenses incurred | 2014-07-31 | $4,660,441 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-07-31 | $4,421,597 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-07-31 | $4,423,809 |
| Value of total assets at end of year | 2014-07-31 | $5,623,609 |
| Value of total assets at beginning of year | 2014-07-31 | $5,075,692 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-07-31 | $238,844 |
| Total interest from all sources | 2014-07-31 | $244 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-07-31 | $174,664 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2014-07-31 | $174,664 |
| Administrative expenses professional fees incurred | 2014-07-31 | $45,977 |
| Was this plan covered by a fidelity bond | 2014-07-31 | Yes |
| Value of fidelity bond cover | 2014-07-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2014-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2014-07-31 | No |
| Contributions received from participants | 2014-07-31 | $1,051,820 |
| Participant contributions at end of year | 2014-07-31 | $112,031 |
| Participant contributions at beginning of year | 2014-07-31 | $92,084 |
| Assets. Other investments not covered elsewhere at end of year | 2014-07-31 | $106,000 |
| Assets. Other investments not covered elsewhere at beginning of year | 2014-07-31 | $408,061 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2014-07-31 | $11,332 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2014-07-31 | $20,572 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2014-07-31 | $127,777 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2014-07-31 | $26,711 |
| Other income not declared elsewhere | 2014-07-31 | $43,067 |
| Administrative expenses (other) incurred | 2014-07-31 | $150,474 |
| Liabilities. Value of operating payables at end of year | 2014-07-31 | $39,121 |
| Liabilities. Value of operating payables at beginning of year | 2014-07-31 | $31,296 |
| Total non interest bearing cash at end of year | 2014-07-31 | $17,473 |
| Total non interest bearing cash at beginning of year | 2014-07-31 | $13,947 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-07-31 | No |
| Value of net income/loss | 2014-07-31 | $439,026 |
| Value of net assets at end of year (total assets less liabilities) | 2014-07-31 | $5,456,711 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-07-31 | $5,017,685 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-07-31 | No |
| Investment advisory and management fees | 2014-07-31 | $42,393 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2014-07-31 | $5,085,731 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2014-07-31 | $4,256,935 |
| Income. Interest from US Government securities | 2014-07-31 | $118 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2014-07-31 | $56,412 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2014-07-31 | $169,526 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2014-07-31 | $169,526 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2014-07-31 | $126 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-07-31 | $4,222,176 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2014-07-31 | $285,205 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-07-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2014-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-07-31 | No |
| Contributions received in cash from employer | 2014-07-31 | $3,371,989 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2014-07-31 | $199,421 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2014-07-31 | $234,630 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2014-07-31 | $114,567 |
| Did the plan have assets held for investment | 2014-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-07-31 | No |
| Aggregate proceeds on sale of assets | 2014-07-31 | $6,590,476 |
| Aggregate carrying amount (costs) on sale of assets | 2014-07-31 | $6,417,998 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-07-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2014-07-31 | Disclaimer |
| Accountancy firm name | 2014-07-31 | GARY G. KRAUSS, CPA,. P.C. |
| Accountancy firm EIN | 2014-07-31 | 161271514 |
| 2013 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2013 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-07-31 | $58,007 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-07-31 | $64,553 |
| Total income from all sources (including contributions) | 2013-07-31 | $3,384,884 |
| Total loss/gain on sale of assets | 2013-07-31 | $90,636 |
| Total of all expenses incurred | 2013-07-31 | $3,482,199 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-07-31 | $3,249,143 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-07-31 | $3,147,536 |
| Value of total assets at end of year | 2013-07-31 | $5,075,692 |
| Value of total assets at beginning of year | 2013-07-31 | $5,179,553 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-07-31 | $233,056 |
| Total interest from all sources | 2013-07-31 | $252 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-07-31 | $152,204 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2013-07-31 | $152,204 |
| Administrative expenses professional fees incurred | 2013-07-31 | $51,900 |
| Was this plan covered by a fidelity bond | 2013-07-31 | Yes |
| Value of fidelity bond cover | 2013-07-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2013-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-07-31 | No |
| Contributions received from participants | 2013-07-31 | $746,852 |
| Participant contributions at end of year | 2013-07-31 | $92,084 |
| Participant contributions at beginning of year | 2013-07-31 | $84,272 |
| Assets. Other investments not covered elsewhere at end of year | 2013-07-31 | $408,061 |
| Assets. Other investments not covered elsewhere at beginning of year | 2013-07-31 | $339,750 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2013-07-31 | $20,572 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2013-07-31 | $41,811 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2013-07-31 | $26,711 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2013-07-31 | $35,553 |
| Other income not declared elsewhere | 2013-07-31 | $49,658 |
| Administrative expenses (other) incurred | 2013-07-31 | $138,980 |
| Liabilities. Value of operating payables at end of year | 2013-07-31 | $31,296 |
| Liabilities. Value of operating payables at beginning of year | 2013-07-31 | $29,000 |
| Total non interest bearing cash at end of year | 2013-07-31 | $13,947 |
| Total non interest bearing cash at beginning of year | 2013-07-31 | $17,635 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-07-31 | No |
| Value of net income/loss | 2013-07-31 | $-97,315 |
| Value of net assets at end of year (total assets less liabilities) | 2013-07-31 | $5,017,685 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-07-31 | $5,115,000 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-07-31 | No |
| Investment advisory and management fees | 2013-07-31 | $42,176 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2013-07-31 | $4,256,935 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2013-07-31 | $4,345,761 |
| Income. Interest from US Government securities | 2013-07-31 | $156 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2013-07-31 | $169,526 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2013-07-31 | $241,366 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2013-07-31 | $241,366 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2013-07-31 | $96 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-07-31 | $3,033,466 |
| Asset value of US Government securities at end of year | 2013-07-31 | $0 |
| Asset value of US Government securities at beginning of year | 2013-07-31 | $25,096 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2013-07-31 | $-55,402 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-07-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2013-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-07-31 | No |
| Contributions received in cash from employer | 2013-07-31 | $2,400,684 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-07-31 | $215,677 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2013-07-31 | $114,567 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2013-07-31 | $83,862 |
| Did the plan have assets held for investment | 2013-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-07-31 | No |
| Aggregate proceeds on sale of assets | 2013-07-31 | $4,242,980 |
| Aggregate carrying amount (costs) on sale of assets | 2013-07-31 | $4,152,344 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-07-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2013-07-31 | Disclaimer |
| Accountancy firm name | 2013-07-31 | GARY G. KRAUSS, CPA, P.C. |
| Accountancy firm EIN | 2013-07-31 | 161271514 |
| 2012 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2012 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-07-31 | $64,553 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-07-31 | $43,908 |
| Total income from all sources (including contributions) | 2012-07-31 | $2,798,845 |
| Total loss/gain on sale of assets | 2012-07-31 | $114,325 |
| Total of all expenses incurred | 2012-07-31 | $2,682,313 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-07-31 | $2,466,264 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-07-31 | $2,419,159 |
| Value of total assets at end of year | 2012-07-31 | $5,179,553 |
| Value of total assets at beginning of year | 2012-07-31 | $5,042,376 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-07-31 | $216,049 |
| Total interest from all sources | 2012-07-31 | $841 |
| Total dividends received (eg from common stock, registered investment company shares) | 2012-07-31 | $171,183 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2012-07-31 | $171,183 |
| Administrative expenses professional fees incurred | 2012-07-31 | $54,363 |
| Was this plan covered by a fidelity bond | 2012-07-31 | Yes |
| Value of fidelity bond cover | 2012-07-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2012-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-07-31 | No |
| Contributions received from participants | 2012-07-31 | $543,685 |
| Assets. Other investments not covered elsewhere at end of year | 2012-07-31 | $339,750 |
| Assets. Other investments not covered elsewhere at beginning of year | 2012-07-31 | $675,500 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2012-07-31 | $41,811 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2012-07-31 | $23,965 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2012-07-31 | $35,553 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2012-07-31 | $23,126 |
| Other income not declared elsewhere | 2012-07-31 | $45,525 |
| Administrative expenses (other) incurred | 2012-07-31 | $120,227 |
| Liabilities. Value of operating payables at end of year | 2012-07-31 | $29,000 |
| Liabilities. Value of operating payables at beginning of year | 2012-07-31 | $20,782 |
| Total non interest bearing cash at end of year | 2012-07-31 | $17,635 |
| Total non interest bearing cash at beginning of year | 2012-07-31 | $13,400 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-07-31 | No |
| Value of net income/loss | 2012-07-31 | $116,532 |
| Value of net assets at end of year (total assets less liabilities) | 2012-07-31 | $5,115,000 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-07-31 | $4,998,468 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-07-31 | No |
| Investment advisory and management fees | 2012-07-31 | $41,459 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2012-07-31 | $4,345,761 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2012-07-31 | $3,704,315 |
| Income. Interest from US Government securities | 2012-07-31 | $715 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2012-07-31 | $241,366 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2012-07-31 | $131,197 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2012-07-31 | $131,197 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2012-07-31 | $126 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-07-31 | $2,270,535 |
| Asset value of US Government securities at end of year | 2012-07-31 | $25,096 |
| Asset value of US Government securities at beginning of year | 2012-07-31 | $279,924 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2012-07-31 | $47,812 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-07-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2012-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-07-31 | No |
| Contributions received in cash from employer | 2012-07-31 | $1,875,474 |
| Employer contributions (assets) at end of year | 2012-07-31 | $84,272 |
| Employer contributions (assets) at beginning of year | 2012-07-31 | $133,683 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-07-31 | $195,729 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2012-07-31 | $83,862 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2012-07-31 | $80,392 |
| Did the plan have assets held for investment | 2012-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-07-31 | No |
| Aggregate proceeds on sale of assets | 2012-07-31 | $4,715,724 |
| Aggregate carrying amount (costs) on sale of assets | 2012-07-31 | $4,601,399 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-07-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2012-07-31 | Disclaimer |
| Accountancy firm name | 2012-07-31 | GARY G. KRAUSS, CPA, P.C. |
| Accountancy firm EIN | 2012-07-31 | 161271514 |
| 2011 : ROCHESTER AREA CONSTRUCTION AND MATERIALS TEAMSTERS HEALTH AND WELFARE FUND 2011 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-07-31 | $43,908 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-07-31 | $40,591 |
| Total income from all sources (including contributions) | 2011-07-31 | $2,723,007 |
| Total loss/gain on sale of assets | 2011-07-31 | $182,988 |
| Total of all expenses incurred | 2011-07-31 | $2,300,700 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-07-31 | $2,073,322 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-07-31 | $2,100,010 |
| Value of total assets at end of year | 2011-07-31 | $5,042,376 |
| Value of total assets at beginning of year | 2011-07-31 | $4,616,752 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-07-31 | $227,378 |
| Total interest from all sources | 2011-07-31 | $6,029 |
| Total dividends received (eg from common stock, registered investment company shares) | 2011-07-31 | $125,647 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-07-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2011-07-31 | $125,647 |
| Administrative expenses professional fees incurred | 2011-07-31 | $46,925 |
| Was this plan covered by a fidelity bond | 2011-07-31 | Yes |
| Value of fidelity bond cover | 2011-07-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2011-07-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-07-31 | No |
| Contributions received from participants | 2011-07-31 | $495,386 |
| Assets. Other investments not covered elsewhere at end of year | 2011-07-31 | $675,500 |
| Assets. Other investments not covered elsewhere at beginning of year | 2011-07-31 | $885,125 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2011-07-31 | $23,965 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2011-07-31 | $26,322 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2011-07-31 | $23,126 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2011-07-31 | $17,184 |
| Other income not declared elsewhere | 2011-07-31 | $47,853 |
| Administrative expenses (other) incurred | 2011-07-31 | $141,068 |
| Liabilities. Value of operating payables at end of year | 2011-07-31 | $20,782 |
| Liabilities. Value of operating payables at beginning of year | 2011-07-31 | $23,407 |
| Total non interest bearing cash at end of year | 2011-07-31 | $13,400 |
| Total non interest bearing cash at beginning of year | 2011-07-31 | $8,956 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-07-31 | No |
| Value of net income/loss | 2011-07-31 | $422,307 |
| Value of net assets at end of year (total assets less liabilities) | 2011-07-31 | $4,998,468 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-07-31 | $4,576,161 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-07-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-07-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-07-31 | No |
| Investment advisory and management fees | 2011-07-31 | $39,385 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2011-07-31 | $3,704,315 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2011-07-31 | $2,847,739 |
| Income. Interest from US Government securities | 2011-07-31 | $5,886 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2011-07-31 | $131,197 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2011-07-31 | $195,499 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2011-07-31 | $195,499 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2011-07-31 | $143 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-07-31 | $1,923,575 |
| Asset value of US Government securities at end of year | 2011-07-31 | $279,924 |
| Asset value of US Government securities at beginning of year | 2011-07-31 | $477,206 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2011-07-31 | $260,480 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-07-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2011-07-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-07-31 | No |
| Contributions received in cash from employer | 2011-07-31 | $1,604,624 |
| Employer contributions (assets) at end of year | 2011-07-31 | $133,683 |
| Employer contributions (assets) at beginning of year | 2011-07-31 | $92,628 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-07-31 | $149,747 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2011-07-31 | $80,392 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2011-07-31 | $83,277 |
| Did the plan have assets held for investment | 2011-07-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-07-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-07-31 | No |
| Aggregate proceeds on sale of assets | 2011-07-31 | $4,373,039 |
| Aggregate carrying amount (costs) on sale of assets | 2011-07-31 | $4,190,051 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-07-31 | Yes |
| Opinion of an independent qualified public accountant for this plan | 2011-07-31 | Disclaimer |
| Accountancy firm name | 2011-07-31 | GARY G KRAUSS, CPA, PC |
| Accountancy firm EIN | 2011-07-31 | 161271514 |
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | 317428 |
| Policy instance | 9 |
| Insurance contract or identification number | 317428 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $497,699 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 510454-0001 |
| Policy instance | 8 |
| Insurance contract or identification number | 510454-0001 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,128 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 7 |
| Insurance contract or identification number | 503215 | | Number of Individuals Covered | 1250 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $199,800 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 89829 |
| Policy instance | 6 |
| Insurance contract or identification number | 89829 | | Number of Individuals Covered | 460 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,928 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MVP HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 706308-0002 |
| Policy instance | 5 |
| Insurance contract or identification number | 706308-0002 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $750 | | 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 $750 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 964369-0001 |
| Policy instance | 4 |
| Insurance contract or identification number | 964369-0001 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $167,194 | | 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 | 313146-0001 |
| Policy instance | 3 |
| Insurance contract or identification number | 313146-0001 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,267 | | 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 | 97177-0002 |
| Policy instance | 2 |
| Insurance contract or identification number | 97177-0002 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $96,395 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNITED HEALTH CARE PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | H2001 |
| Policy instance | 1 |
| Insurance contract or identification number | H2001 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $153,905 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | 317428 |
| Policy instance | 24 |
| Insurance contract or identification number | 317428 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,206 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | 317428 |
| Policy instance | 11 |
| Insurance contract or identification number | 317428 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $459,370 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 501410-0001 |
| Policy instance | 12 |
| Insurance contract or identification number | 501410-0001 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,945 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE UNION LABOR LIFE INSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 52414 ) |
| Policy contract number | G-3263 |
| Policy instance | 13 |
| Insurance contract or identification number | G-3263 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,599 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,599 | | Additional information about fees paid to insurance broker | FULFILLMENT OF COMMISSION AGREEMENT |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 800632-2010 |
| Policy instance | 21 |
| Insurance contract or identification number | 800632-2010 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Welfare Benefit Premiums Paid to Carrier | USD $35,429 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 100221 |
| Policy instance | 20 |
| Insurance contract or identification number | 100221 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,142 | | 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 | 6457 |
| Policy instance | 19 |
| Insurance contract or identification number | 6457 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $750,900 | | 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 | 706308-0001 |
| Policy instance | 18 |
| Insurance contract or identification number | 706308-0001 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of fees paid to insurance company | USD $66,366 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,904,629 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 66366 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 34065-0001 |
| Policy instance | 17 |
| Insurance contract or identification number | 34065-0001 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $166,785 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STAFF BENEFITS MANAGEMENT, INC (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | RCM 5830001 |
| Policy instance | 16 |
| Insurance contract or identification number | RCM 5830001 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,442 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 17207-0001 |
| Policy instance | 15 |
| Insurance contract or identification number | 17207-0001 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,460 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $135,937 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,460 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 312000-0001 |
| Policy instance | 14 |
| Insurance contract or identification number | 312000-0001 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $843,886 | | 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 | 6914-0001 |
| Policy instance | 22 |
| Insurance contract or identification number | 6914-0001 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | 317428 |
| Policy instance | 9 |
| Insurance contract or identification number | 317428 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | 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 | 510454-0001 |
| Policy instance | 8 |
| Insurance contract or identification number | 510454-0001 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 7 |
| Insurance contract or identification number | 503215 | | Number of Individuals Covered | 1299 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Vision 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 | 89829 |
| Policy instance | 6 |
| Insurance contract or identification number | 89829 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of fees paid to insurance company | USD $11,021 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 11021 | | Insurance broker organization code? | 3 |
|
| MVP HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 706308-0002 |
| Policy instance | 5 |
| Insurance contract or identification number | 706308-0002 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | 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 | 313146-0001 |
| Policy instance | 3 |
| Insurance contract or identification number | 313146-0001 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | 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 | 97177-0002 |
| Policy instance | 2 |
| Insurance contract or identification number | 97177-0002 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED HEALTH CARE PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | H2001 |
| Policy instance | 1 |
| Insurance contract or identification number | H2001 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | 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 | 964369-0001 |
| Policy instance | 4 |
| Insurance contract or identification number | 964369-0001 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | 317428 |
| Policy instance | 11 |
| Insurance contract or identification number | 317428 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | 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 | 501410-0001 |
| Policy instance | 12 |
| Insurance contract or identification number | 501410-0001 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ULLICO LIFE INSURANCE (National Association of Insurance Commissioners NAIC id number: 85090 ) |
| Policy contract number | G-3263 |
| Policy instance | 13 |
| Insurance contract or identification number | G-3263 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $5,767 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,767 | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 706308-0001 |
| Policy instance | 18 |
| Insurance contract or identification number | 706308-0001 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | 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 | 6914-0001 |
| Policy instance | 22 |
| Insurance contract or identification number | 6914-0001 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | 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 | 800632-2010 |
| Policy instance | 21 |
| Insurance contract or identification number | 800632-2010 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | 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 | 100221 |
| Policy instance | 20 |
| Insurance contract or identification number | 100221 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 6457 |
| Policy instance | 19 |
| Insurance contract or identification number | 6457 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $33,904 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,904 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 34065-0001 |
| Policy instance | 17 |
| Insurance contract or identification number | 34065-0001 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STAFF BENEFITS MANAGEMENT, INC (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | RCM 5830001 |
| Policy instance | 16 |
| Insurance contract or identification number | RCM 5830001 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | 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 | 17207-0001 |
| Policy instance | 15 |
| Insurance contract or identification number | 17207-0001 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | 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 | 312000-0001 |
| Policy instance | 14 |
| Insurance contract or identification number | 312000-0001 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | 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 | 89829 |
| Policy instance | 1 |
| Insurance contract or identification number | 89829 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,847 | | Insurance broker organization code? | 3 |
|
| STAFF BENEFITS MANAGEMENT, INC (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | RCM 5830001 |
| Policy instance | 10 |
| Insurance contract or identification number | RCM 5830001 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $84,951 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | H2001 |
| Policy instance | 9 |
| Insurance contract or identification number | H2001 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $270,096 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 6914-0001 |
| Policy instance | 8 |
| Insurance contract or identification number | 6914-0001 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $432,135 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,631 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 800632-2010 |
| Policy instance | 7 |
| Insurance contract or identification number | 800632-2010 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $28,692 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 706308-0001 |
| Policy instance | 6 |
| Insurance contract or identification number | 706308-0001 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,997,174 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $74,858 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 94369-0001 |
| Policy instance | 5 |
| Insurance contract or identification number | 94369-0001 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $134,989 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,629 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 313146-0001 |
| Policy instance | 4 |
| Insurance contract or identification number | 313146-0001 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,909 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $359 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 312000-0001 |
| Policy instance | 3 |
| Insurance contract or identification number | 312000-0001 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $725,636 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,476 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 97177-0002 |
| Policy instance | 2 |
| Insurance contract or identification number | 97177-0002 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $94,931 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,962 | | Insurance broker organization code? | 3 |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 11 |
| Insurance contract or identification number | 503215 | | Number of Individuals Covered | 1403 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $216,916 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 6457 |
| Policy instance | 13 |
| Insurance contract or identification number | 6457 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $35,246 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $854,964 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,250 | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | 317428 |
| Policy instance | 12 |
| Insurance contract or identification number | 317428 | | Number of Individuals Covered | 148 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $386,037 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 706308-0002 |
| Policy instance | 22 |
| Insurance contract or identification number | 706308-0002 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,138 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,431 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,288 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 510454-0001 |
| Policy instance | 21 |
| Insurance contract or identification number | 510454-0001 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $30,639 | | 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 | 34065-0001 |
| Policy instance | 20 |
| Insurance contract or identification number | 34065-0001 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $169,283 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,071 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 501410-0001 |
| Policy instance | 19 |
| Insurance contract or identification number | 501410-0001 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,293 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $125,620 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,388 |
|
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | 317428 |
| Policy instance | 18 |
| Insurance contract or identification number | 317428 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,424 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | 317428 |
| Policy instance | 17 |
| Insurance contract or identification number | 317428 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $15,424 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 17207-0001 |
| Policy instance | 16 |
| Insurance contract or identification number | 17207-0001 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $145,874 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,020 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 100221 |
| Policy instance | 15 |
| Insurance contract or identification number | 100221 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $857 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $27,514 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $987 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 97177-0002 |
| Policy instance | 15 |
| Insurance contract or identification number | 97177-0002 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $99,555 | | 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 | 312000-0001 |
| Policy instance | 17 |
| Insurance contract or identification number | 312000-0001 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $322,810 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STAFF BENEFITS MANAGEMENT, INC (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | RCM 58300001 |
| Policy instance | 19 |
| Insurance contract or identification number | RCM 58300001 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $26,726 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 20 |
| Insurance contract or identification number | 503215 | | Number of Individuals Covered | 1487 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $226,657 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ULLICO LIFE INSURANCE (National Association of Insurance Commissioners NAIC id number: 85090 ) |
| Policy contract number | G-3263 |
| Policy instance | 21 |
| Insurance contract or identification number | G-3263 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $60,419 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | 317428 |
| Policy instance | 26 |
| Insurance contract or identification number | 317428 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $153,588 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | 317428 |
| Policy instance | 27 |
| Insurance contract or identification number | 317428 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $238,128 | | 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 | 313146-0001 |
| Policy instance | 14 |
| Insurance contract or identification number | 313146-0001 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,746 | | 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 | 94369-0001 |
| Policy instance | 13 |
| Insurance contract or identification number | 2942 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $292 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | Yes | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Welfare Benefit Premiums Paid to Carrier | USD $105,423 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 34065-0001 |
| Policy instance | 12 |
| Insurance contract or identification number | 34065-0001 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $141,327 | | 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 | 6914-0001 |
| Policy instance | 10 |
| Insurance contract or identification number | 6914-0001 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $432,992 | | 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 | 800632-201 0 |
| Policy instance | 9 |
| Insurance contract or identification number | 800632-201 0 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $33,603 | | 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 | 706308-0002 |
| Policy instance | 8 |
| Insurance contract or identification number | 706308-0002 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,138 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,138 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 706308-0001 |
| Policy instance | 7 |
| Insurance contract or identification number | 706308-0001 | | Number of Individuals Covered | 244 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $71,114 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $71,114 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 100221 |
| Policy instance | 6 |
| Insurance contract or identification number | 100221 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $857 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $23,336 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $857 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 89829 |
| Policy instance | 5 |
| Insurance contract or identification number | 89829 | | Number of Individuals Covered | 500 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $11,740 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,740 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 6457 |
| Policy instance | 3 |
| Insurance contract or identification number | 6457 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $37,182 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $926,543 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,182 | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY OF NE (National Association of Insurance Commissioners NAIC id number: 12634 ) |
| Policy contract number | 317428 |
| Policy instance | 28 |
| Insurance contract or identification number | 317428 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $8,863 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED HEALTH CARE PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | H2001 |
| Policy instance | 29 |
| Insurance contract or identification number | H2001 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $288,427 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ULLICO LIFE INSURANCE (National Association of Insurance Commissioners NAIC id number: 85090 ) |
| Policy contract number | G-3263 |
| Policy instance | 30 |
| Insurance contract or identification number | G-3263 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $60,419 | | 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 | 501410 |
| Policy instance | 2 |
| Insurance contract or identification number | 501410 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $790 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $206,380 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $790 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 17207-0001 |
| Policy instance | 16 |
| Insurance contract or identification number | 17207-0001 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $153,917 | | 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 | 92760-0001 |
| Policy instance | 11 |
| Insurance contract or identification number | 92760-0001 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $20,180 | | 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 | 510454 |
| Policy instance | 1 |
| Insurance contract or identification number | 510454 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,550 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $31,522 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,550 | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 706308-0001 |
| Policy instance | 10 |
| Insurance contract or identification number | 706308-0001 | | Number of Individuals Covered | 292 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $74,811 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,007,841 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $74,811 | | Insurance broker organization code? | 3 |
|
| ULLICO LIFE INSURANCE (National Association of Insurance Commissioners NAIC id number: 85090 ) |
| Policy contract number | G-3263 |
| Policy instance | 12 |
| Insurance contract or identification number | G-3263 | | Number of Individuals Covered | 274 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $66,605 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 14 |
| Insurance contract or identification number | 503215 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $227,420 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 92760-0001 |
| Policy instance | 15 |
| Insurance contract or identification number | 92760-0001 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,602 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $64,162 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,602 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 6914-0001 |
| Policy instance | 16 |
| Insurance contract or identification number | 6914-0001 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $15,839 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $389,579 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,839 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 501410 |
| Policy instance | 17 |
| Insurance contract or identification number | 501410 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $218,123 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 6325027 |
| Policy instance | 13 |
| Insurance contract or identification number | 6325027 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $16,000 | | Total amount of fees paid to insurance company | USD $24,919 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $195,656 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,994 | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 706308-0002 |
| Policy instance | 11 |
| Insurance contract or identification number | 706308-0002 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $4,888 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $88,546 | | 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 | 800632-201 |
| Policy instance | 9 |
| Insurance contract or identification number | 800632-201 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $37,949 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 0034065-0001 |
| Policy instance | 8 |
| Insurance contract or identification number | 0034065-0001 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $6,904 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $172,611 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,904 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 313146-0001 |
| Policy instance | 7 |
| Insurance contract or identification number | 313146-0001 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $573 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,331 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $573 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 100221-0001 |
| Policy instance | 6 |
| Insurance contract or identification number | 100221-0001 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $926 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $23,150 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $926 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 6457 |
| Policy instance | 5 |
| Insurance contract or identification number | 6457 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $34,863 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $871,586 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,863 | | Insurance broker organization code? | 3 |
|
| UNITED HEALTH CARE PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | H2001 |
| Policy instance | 2 |
| Insurance contract or identification number | H2001 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $279,224 | | 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 | 510454-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 510454-0001 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $40,464 | | 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 | 94369 |
| Policy instance | 4 |
| Insurance contract or identification number | 94369 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $4,357 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $108,935 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,357 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00097177 |
| Policy instance | 3 |
| Insurance contract or identification number | 00097177 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $4,155 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $103,864 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,155 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 10221-0001 |
| Policy instance | 17 |
| Insurance contract or identification number | 10221-0001 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $281 | | Total amount of fees paid to insurance company | USD $281 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $21,063 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | G-3263 |
| Policy instance | 1 |
| Insurance contract or identification number | G-3263 | | Number of Individuals Covered | 278 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $6,804 | | Total amount of fees paid to insurance company | USD $6,804 | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $68,038 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SIERRA HEALTH & LIFE (National Association of Insurance Commissioners NAIC id number: 71420 ) |
| Policy contract number | H2001 |
| Policy instance | 2 |
| Insurance contract or identification number | H2001 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $287,708 | | 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 | 800632-201 |
| Policy instance | 3 |
| Insurance contract or identification number | 800632-201 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $13,194 | | Total amount of fees paid to insurance company | USD $13,194 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $42,526 | | 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 | 0034065-0001 |
| Policy instance | 4 |
| Insurance contract or identification number | 0034065-0001 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $165,326 | | 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 | 94369-0001 |
| Policy instance | 5 |
| Insurance contract or identification number | 94369-0001 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | 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 | 0097177-0002 |
| Policy instance | 7 |
| Insurance contract or identification number | 0097177-0002 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $91,778 | | 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 | 706308-0001 |
| Policy instance | 8 |
| Insurance contract or identification number | 706308-0001 | | Number of Individuals Covered | 186 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $85,857 | | Total amount of fees paid to insurance company | USD $85,857 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,496,877 | | 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 | 706308-0002 |
| Policy instance | 9 |
| Insurance contract or identification number | 706308-0002 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $138,162 | | 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 | 501410 |
| Policy instance | 16 |
| Insurance contract or identification number | 501410 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $276,018 | | 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 | 6325027 |
| Policy instance | 15 |
| Insurance contract or identification number | 6325027 | | Number of Individuals Covered | 263 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $174,750 | | 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 | 92760-0001 |
| Policy instance | 14 |
| Insurance contract or identification number | 92760-0001 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $57,860 | | 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 | 510454 |
| Policy instance | 13 |
| Insurance contract or identification number | 510454 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $50,923 | | 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 | 00006457 |
| Policy instance | 11 |
| Insurance contract or identification number | 00006457 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $13,194 | | Total amount of fees paid to insurance company | USD $13,194 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $813,625 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 10 |
| Insurance contract or identification number | 503215 | | Number of Individuals Covered | 1280 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $192,214 | | 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 | 100172-0001 |
| Policy instance | 2 |
| Insurance contract or identification number | 100172-0001 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $114,490 | | 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 | 000943690001 |
| Policy instance | 3 |
| Insurance contract or identification number | 000943690001 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $103,832 | | 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 | 0009267600001 |
| Policy instance | 4 |
| Insurance contract or identification number | 0009267600001 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $57,802 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | G-3263 |
| Policy instance | 5 |
| Insurance contract or identification number | G-3263 | | Number of Individuals Covered | 283 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $53,831 | | 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 | 706308-0002 |
| Policy instance | 12 |
| Insurance contract or identification number | 706308-0002 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $183,465 | | 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 | 00034065-0001 |
| Policy instance | 8 |
| Insurance contract or identification number | 00034065-0001 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $171,998 | | 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 | 6325027 |
| Policy instance | 9 |
| Insurance contract or identification number | 6325027 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $178,051 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 10 |
| Insurance contract or identification number | 503215 | | Number of Individuals Covered | 1281 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $181,330 | | 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 | 00096637-0001 |
| Policy instance | 6 |
| Insurance contract or identification number | 00096637-0001 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $147,020 | | 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 | 00097177-0002 |
| Policy instance | 16 |
| Insurance contract or identification number | 00097177-0002 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $40,214 | | 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 | 800632-201 |
| Policy instance | 15 |
| Insurance contract or identification number | 800632-201 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $37,336 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 510454 |
| Policy instance | 14 |
| Insurance contract or identification number | 510454 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $53,706 | | 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 | 501410 |
| Policy instance | 13 |
| Insurance contract or identification number | 501410 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $439,673 | | 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 | 100221-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 100221-0001 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,023 | | 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 | 00006457 |
| Policy instance | 7 |
| Insurance contract or identification number | 00006457 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $688,942 | | 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 | 706308-0001 |
| Policy instance | 11 |
| Insurance contract or identification number | 706308-0001 | | Number of Individuals Covered | 211 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,434,705 | | 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 | 800632-201 |
| Policy instance | 15 |
| Insurance contract or identification number | 800632-201 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,610 | | 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 | 100172-0001 |
| Policy instance | 2 |
| Insurance contract or identification number | 100172-0001 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $129,230 | | 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 | 10221-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10221-0001 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,784 | | 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 | 000943690001 |
| Policy instance | 3 |
| Insurance contract or identification number | 000943690001 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $97,975 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 0 | | Insurance broker name | INDIVIDUAL CONTRACT RATES |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00034065-0001 |
| Policy instance | 8 |
| Insurance contract or identification number | 00034065-0001 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $160,277 | | 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 | 000927600001 |
| Policy instance | 4 |
| Insurance contract or identification number | 000927600001 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $51,999 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | FNYH893295 |
| Policy instance | 5 |
| Insurance contract or identification number | FNYH893295 | | Number of Individuals Covered | 291 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $59,585 | | 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 | 00096637-0001 |
| Policy instance | 6 |
| Insurance contract or identification number | 00096637-0001 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $150,836 | | 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 | 0000645-001 |
| Policy instance | 7 |
| Insurance contract or identification number | 0000645-001 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $738,800 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 10 |
| Insurance contract or identification number | 503215 | | Number of Individuals Covered | 1251 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $150,957 | | 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 | 706308-0001 |
| Policy instance | 11 |
| Insurance contract or identification number | 706308-0001 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,511,058 | | 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 | 706308-0002 |
| Policy instance | 12 |
| Insurance contract or identification number | 706308-0002 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $141,566 | | 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 | 501410 |
| Policy instance | 13 |
| Insurance contract or identification number | 501410 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $335,044 | | 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 | 510454 |
| Policy instance | 14 |
| Insurance contract or identification number | 510454 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $39,494 | | 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 | 6325027 |
| Policy instance | 9 |
| Insurance contract or identification number | 6325027 | | Number of Individuals Covered | 249 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $177,065 | | 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 | 19532-0001 |
| Policy instance | 15 |
| Insurance contract or identification number | 19532-0001 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,146 | | 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 | 000943690001 |
| Policy instance | 3 |
| Insurance contract or identification number | 000943690001 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $101,993 | | 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 | 000927600001 |
| Policy instance | 4 |
| Insurance contract or identification number | 000927600001 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $60,948 | | 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 | 8006322010 |
| Policy instance | 5 |
| Insurance contract or identification number | 8006322010 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $21,105 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | FNYH893295 |
| Policy instance | 6 |
| Insurance contract or identification number | FNYH893295 | | Number of Individuals Covered | 287 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $59,381 | | 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 | 00006457 |
| Policy instance | 8 |
| Insurance contract or identification number | 00006457 | | Number of Individuals Covered | 90 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $718,125 | | 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 | 00034065-0001 |
| Policy instance | 9 |
| Insurance contract or identification number | 00034065-0001 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $190,483 | | 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 | 00096637-0001 |
| Policy instance | 7 |
| Insurance contract or identification number | 00096637-0001 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $172,824 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 11 |
| Insurance contract or identification number | 503215 | | Number of Individuals Covered | 959 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $143,797 | | 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 | 706308-0001 |
| Policy instance | 12 |
| Insurance contract or identification number | 706308-0001 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,264,422 | | 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 | 501410 |
| Policy instance | 14 |
| Insurance contract or identification number | 501410 | | Number of Individuals Covered | 132 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $242,900 | | 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 | 510454 |
| Policy instance | 16 |
| Insurance contract or identification number | 510454 | | Number of Individuals Covered | 18 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $43,641 | | 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 | 100172-0001 |
| Policy instance | 2 |
| Insurance contract or identification number | 100172-0001 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $160,048 | | 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 | 100221-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 100221-0001 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,305 | | 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 | 6325027 |
| Policy instance | 10 |
| Insurance contract or identification number | 6325027 | | Number of Individuals Covered | 258 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $180,967 | | 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 | 706308-0002 |
| Policy instance | 13 |
| Insurance contract or identification number | 706308-0002 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $49,284 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | FNYH893295 |
| Policy instance | 13 |
| Insurance contract or identification number | FNYH893295 | | Number of Individuals Covered | 289 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,480 | | 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 | 6325027 |
| Policy instance | 3 |
| Insurance contract or identification number | 6325027 | | Number of Individuals Covered | 472 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $150,996 | | 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 | 000927600001 |
| Policy instance | 8 |
| Insurance contract or identification number | 000927600001 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 $55,854 | | 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 | 6326515 |
| Policy instance | 4 |
| Insurance contract or identification number | 6326515 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $206,769 | | 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 | 000195320001 |
| Policy instance | 5 |
| Insurance contract or identification number | 000195320001 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,279 | | 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 | 00100221-0001 |
| Policy instance | 6 |
| Insurance contract or identification number | 00100221-0001 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 $18,371 | | 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 | 001001720001 |
| Policy instance | 7 |
| Insurance contract or identification number | 001001720001 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 $150,299 | | 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 | 000943690001 |
| Policy instance | 9 |
| Insurance contract or identification number | 000943690001 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $84,379 | | 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 | 00096637-0001 |
| Policy instance | 10 |
| Insurance contract or identification number | 00096637-0001 | | Number of Individuals Covered | 32 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $136,405 | | 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: 95521 ) |
| Policy contract number | GROUP X0181 |
| Policy instance | 11 |
| Insurance contract or identification number | GROUP X0181 | | Number of Individuals Covered | 239 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 $901,217 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 12 |
| Insurance contract or identification number | 503215 | | Number of Individuals Covered | 2156 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $139,719 | | 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 | 00006457 |
| Policy instance | 2 |
| Insurance contract or identification number | 00006457 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 $485,850 | | 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 | 6320016 |
| Policy instance | 1 |
| Insurance contract or identification number | 6320016 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 $12,391 | | 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 | 00034065-0001 |
| Policy instance | 15 |
| Insurance contract or identification number | 00034065-0001 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 $194,122 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 800632-201 0 |
| Policy instance | 14 |
| Insurance contract or identification number | 800632-201 0 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $14,638 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00006457 |
| Policy instance | 2 |
| Insurance contract or identification number | 00006457 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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 $380,548 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 12 |
| Insurance contract or identification number | 503215 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $132,449 | | 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 | 6320016 |
| Policy instance | 1 |
| Insurance contract or identification number | 6320016 | | 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 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $73,501 | | 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 | 6326515 |
| Policy instance | 4 |
| Insurance contract or identification number | 6326515 | | Number of Individuals Covered | 84 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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 $193,910 | | 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 | 6325027 |
| Policy instance | 3 |
| Insurance contract or identification number | 6325027 | | Number of Individuals Covered | 206 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental 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 | 000195320001 |
| Policy instance | 5 |
| Insurance contract or identification number | 000195320001 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $10,828 | | 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 | 000943690001 |
| Policy instance | 9 |
| Insurance contract or identification number | 000943690001 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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 $80,417 | | 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 | 000927600001 |
| Policy instance | 8 |
| Insurance contract or identification number | 000927600001 | | Number of Individuals Covered | 18 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $53,432 | | 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 | 00100221-0001 |
| Policy instance | 6 |
| Insurance contract or identification number | 00100221-0001 | | 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 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,780 | | 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: 95521 ) |
| Policy contract number | GROUP X0181 |
| Policy instance | 11 |
| Insurance contract or identification number | GROUP X0181 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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 $810,786 | | 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 | 001001720001 |
| Policy instance | 7 |
| Insurance contract or identification number | 001001720001 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2011-01-11 | | Insurance policy end date | 2011-12-31 | | 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 $142,071 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | FNYH893295 |
| Policy instance | 13 |
| Insurance contract or identification number | FNYH893295 | | Number of Individuals Covered | 280 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $57,817 | | 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 | 8006322010 |
| Policy instance | 10 |
| Insurance contract or identification number | 8006322010 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $13,330 | | 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 | 6320016 |
| Policy instance | 5 |
| Insurance contract or identification number | 6320016 | | Number of Individuals Covered | 63 | | 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 $392,834 | | 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 | 6326515 |
| Policy instance | 4 |
| Insurance contract or identification number | 6326515 | | Number of Individuals Covered | 82 | | 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 $194,272 | | 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 | 00019320001 |
| Policy instance | 3 |
| Insurance contract or identification number | 00019320001 | | 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 $9,734 | | 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 | 8006322010 |
| Policy instance | 2 |
| Insurance contract or identification number | 8006322010 | | Number of Individuals Covered | 18 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $19,770 | | 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: 95521 ) |
| Policy contract number | GROUP X0181 |
| Policy instance | 6 |
| Insurance contract or identification number | GROUP X0181 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $729,020 | | 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 | 000927600001 |
| Policy instance | 8 |
| Insurance contract or identification number | 000927600001 | | 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 $29,191 | | 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 | 00006457 |
| Policy instance | 7 |
| Insurance contract or identification number | 00006457 | | 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 | | Dental Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $97,688 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | FNYH893295 |
| Policy instance | 9 |
| Insurance contract or identification number | FNYH893295 | | Number of Individuals Covered | 276 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $3,214 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $57,375 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 503215 |
| Policy instance | 10 |
| Insurance contract or identification number | 503215 | | Number of Individuals Covered | 745 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $111,233 | | 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 | 6325027 |
| Policy instance | 11 |
| Insurance contract or identification number | 6325027 | | Number of Individuals Covered | 180 | | 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 | | Dental 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 | 00100221-0001 |
| Policy instance | 12 |
| Insurance contract or identification number | 00100221-0001 | | 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 $16,432 | | 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 | 000943690001 |
| Policy instance | 1 |
| Insurance contract or identification number | 000943690001 | | 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 $19,939 | | 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 | 001001720001 |
| Policy instance | 13 |
| Insurance contract or identification number | 001001720001 | | Number of Individuals Covered | 15 | | 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 $137,300 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
