401k Plan data: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN plan

COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN
Plan identification number	501

COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

COSTANZO'S BAKERY, LLC has sponsored the creation of one or more 401k plans.

Company Name: COSTANZO'S BAKERY, LLC

Employer identification number (EIN): 161077221

NAIC Classification: 311800
NAIC Description: Bakeries and Tortilla Manufacturing

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01 LORI FERRARACCIO 2021-08-24
501 2019-01-01 LORI FERRARACCIO 2020-08-19
501 2018-01-01 LORI FERRARACCIO 2020-06-19
501 2017-01-01 LORI FERRARACCIO 2020-06-19
501 2016-01-01 LORI FERRARACCIO 2020-06-19
501 2015-01-01 LORI FERRARACCIO 2020-06-19
501 2014-01-01 LORI FERRARACCIO 2020-06-19
501 2013-01-01 LORI FERRARACCIO 2020-06-19
501 2012-01-01 LORI FERRARACCIO 2020-06-19

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01	LORI FERRARACCIO	2021-08-24
501	2019-01-01	LORI FERRARACCIO	2020-08-19
501	2018-01-01	LORI FERRARACCIO	2020-06-19
501	2017-01-01	LORI FERRARACCIO	2020-06-19
501	2016-01-01	LORI FERRARACCIO	2020-06-19
501	2015-01-01	LORI FERRARACCIO	2020-06-19
501	2014-01-01	LORI FERRARACCIO	2020-06-19
501	2013-01-01	LORI FERRARACCIO	2020-06-19
501	2012-01-01	LORI FERRARACCIO	2020-06-19

Plan Statistics for COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 127
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 137
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 137
2021: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 141
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 121
Number of retired or separated participants receiving benefits 2021-01-01 3
Number of other retired or separated participants entitled to future benefits 2021-01-01 3
Total of all active and inactive participants 2021-01-01 127
2020: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 131
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 159
Number of retired or separated participants receiving benefits 2020-01-01 3
Total of all active and inactive participants 2020-01-01 162
2019: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 128
Number of retired or separated participants receiving benefits 2019-01-01 3
Total of all active and inactive participants 2019-01-01 131
2018: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 122
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 107
Number of retired or separated participants receiving benefits 2018-01-01 3
Total of all active and inactive participants 2018-01-01 110
2017: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 114
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 110
Number of retired or separated participants receiving benefits 2017-01-01 3
Total of all active and inactive participants 2017-01-01 113
2016: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 110
Number of retired or separated participants receiving benefits 2016-01-01 4
Total of all active and inactive participants 2016-01-01 114
2015: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 126
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 114
Number of retired or separated participants receiving benefits 2015-01-01 4
Total of all active and inactive participants 2015-01-01 118
2014: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 116
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 122
Number of retired or separated participants receiving benefits 2014-01-01 4
Total of all active and inactive participants 2014-01-01 126
2013: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 103
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 112
Number of retired or separated participants receiving benefits 2013-01-01 4
Total of all active and inactive participants 2013-01-01 116
2012: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 88
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 103
Total of all active and inactive participants 2012-01-01 103

Measure	Date	Value
2022: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	127
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	137
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	137
2021: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	121
Number of retired or separated participants receiving benefits	2021-01-01	3
Number of other retired or separated participants entitled to future benefits	2021-01-01	3
Total of all active and inactive participants	2021-01-01	127
2020: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	131
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	159
Number of retired or separated participants receiving benefits	2020-01-01	3
Total of all active and inactive participants	2020-01-01	162
2019: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	128
Number of retired or separated participants receiving benefits	2019-01-01	3
Total of all active and inactive participants	2019-01-01	131
2018: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	122
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	107
Number of retired or separated participants receiving benefits	2018-01-01	3
Total of all active and inactive participants	2018-01-01	110
2017: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	110
Number of retired or separated participants receiving benefits	2017-01-01	3
Total of all active and inactive participants	2017-01-01	113
2016: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	110
Number of retired or separated participants receiving benefits	2016-01-01	4
Total of all active and inactive participants	2016-01-01	114
2015: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	126
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	114
Number of retired or separated participants receiving benefits	2015-01-01	4
Total of all active and inactive participants	2015-01-01	118
2014: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	116
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	122
Number of retired or separated participants receiving benefits	2014-01-01	4
Total of all active and inactive participants	2014-01-01	126
2013: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	103
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	112
Number of retired or separated participants receiving benefits	2013-01-01	4
Total of all active and inactive participants	2013-01-01	116
2012: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	88
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	103
Total of all active and inactive participants	2012-01-01	103

Form 5500 Responses for COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN

2022: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: COSTANZO'S BAKERY LLC EMPLOYEE BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	First time form 5500 has been submitted	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

SYK600265

Policy instance

Insurance contract or identification number	SYK600265
Number of Individuals Covered	137
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	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	BASIC & VOLUNTARY AD&D
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 $2,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $292
Insurance broker organization code?	3

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

Policy contract number

00358700

Policy instance

Insurance contract or identification number	00358700
Number of Individuals Covered	96
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,342
Total amount of fees paid to insurance company	USD $4,629
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	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
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 $72,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,342
Amount paid for insurance broker fees	4629
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E3957883

Policy instance

Insurance contract or identification number	E3957883
Number of Individuals Covered	14
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $780
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CANCER, HOSPITAL CONFINEMENT
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 $11,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $429
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NLT41

Policy instance

Insurance contract or identification number	NLT41
Number of Individuals Covered	21
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,575
Total amount of fees paid to insurance company	USD $307
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CANCER
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 $25,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,549
Amount paid for insurance broker fees	209
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

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

Policy contract number

SYK600265

Policy instance

Insurance contract or identification number	SYK600265
Number of Individuals Covered	0
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $47
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	47
Additional information about fees paid to insurance broker	OVERRIDE FEES
Insurance broker organization code?	3

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

Policy contract number

SGN600599

Policy instance

Insurance contract or identification number	SGN600599
Number of Individuals Covered	0
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $578
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	578
Additional information about fees paid to insurance broker	OVERRIDE FEES
Insurance broker organization code?	3

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

Policy contract number

SGN600599

Policy instance

Insurance contract or identification number	SGN600599
Number of Individuals Covered	137
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,626
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY TERM LIFE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $29,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,626
Insurance broker organization code?	3

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

Policy contract number

00358700

Policy instance

Insurance contract or identification number	00358700
Number of Individuals Covered	94
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,502
Total amount of fees paid to insurance company	USD $6,447
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	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
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 $76,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,502
Amount paid for insurance broker fees	6447
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

00404354

Policy instance

Insurance contract or identification number	00404354
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $405
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 $8,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $405
Insurance broker organization code?	3

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E3957883

Policy instance

Insurance contract or identification number	E3957883
Number of Individuals Covered	21
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $796
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CANCER, HOSPITAL CONFINEMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $433
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NLT41

Policy instance

Insurance contract or identification number	NLT41
Number of Individuals Covered	16
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,368
Total amount of fees paid to insurance company	USD $134
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CANCER
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 $26,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,985
Amount paid for insurance broker fees	92
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

SYK600265

Policy instance

Insurance contract or identification number	SYK600265
Number of Individuals Covered	42
Insurance policy start date	2021-06-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $25
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH
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 $209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25
Insurance broker organization code?	3

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

Policy contract number

SGN600599

Policy instance

Insurance contract or identification number	SGN600599
Number of Individuals Covered	42
Insurance policy start date	2021-06-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $319
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $319
Insurance broker organization code?	3

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

Policy contract number

SGN600599

Policy instance

Insurance contract or identification number	SGN600599
Number of Individuals Covered	77
Insurance policy start date	2021-06-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,412
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,412
Insurance broker organization code?	3

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

Policy contract number

SYK600265

Policy instance

Insurance contract or identification number	SYK600265
Number of Individuals Covered	77
Insurance policy start date	2021-06-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $166
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BASIC & VOLUNTARY AD&D
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 $966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $166
Insurance broker organization code?	3

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

Policy contract number

00358700

Policy instance

Insurance contract or identification number	00358700
Number of Individuals Covered	113
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,968
Total amount of fees paid to insurance company	USD $5,649
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,968
Amount paid for insurance broker fees	5649
Insurance broker organization code?	3

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

Policy contract number

00404354

Policy instance

Insurance contract or identification number	00404354
Number of Individuals Covered	3
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $540
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $20,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $540
Insurance broker organization code?	3

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E3957883

Policy instance

Insurance contract or identification number	E3957883
Number of Individuals Covered	21
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $796
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSPITAL CONFINEMENT
Welfare Benefit Premiums Paid to Carrier	USD $13,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $433
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NLT41

Policy instance

Insurance contract or identification number	NLT41
Number of Individuals Covered	20
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,121
Total amount of fees paid to insurance company	USD $35
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $26,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,903
Amount paid for insurance broker fees	25
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SYK600265

Policy instance

Insurance contract or identification number	SYK600265
Number of Individuals Covered	159
Insurance policy start date	2020-06-01
Insurance policy end date	2021-06-01
Total amount of commissions paid to insurance broker	USD $297
Total amount of fees paid to insurance company	USD $70
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $2,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $297
Amount paid for insurance broker fees	70
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGN600599

Policy instance

Insurance contract or identification number	SGN600599
Number of Individuals Covered	159
Insurance policy start date	2020-06-01
Insurance policy end date	2021-06-01
Total amount of commissions paid to insurance broker	USD $2,549
Total amount of fees paid to insurance company	USD $825
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,549
Amount paid for insurance broker fees	825
Insurance broker organization code?	3

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

Policy contract number

SGN600599

Policy instance

Insurance contract or identification number	SGN600599
Number of Individuals Covered	128
Insurance policy start date	2019-06-01
Insurance policy end date	2020-06-01
Total amount of commissions paid to insurance broker	USD $2,042
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,042
Insurance broker organization code?	3

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

Policy contract number

SYK600265

Policy instance

Insurance contract or identification number	SYK600265
Number of Individuals Covered	128
Insurance policy start date	2019-06-01
Insurance policy end date	2020-06-01
Total amount of commissions paid to insurance broker	USD $200
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $1,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $200
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NLT41

Policy instance

Insurance contract or identification number	NLT41
Number of Individuals Covered	20
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,698
Total amount of fees paid to insurance company	USD $268
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $32,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,399
Amount paid for insurance broker fees	149
Insurance broker organization code?	3

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E3957883

Policy instance

Insurance contract or identification number	E3957883
Number of Individuals Covered	23
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $934
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSPITAL CONFINEMENT
Welfare Benefit Premiums Paid to Carrier	USD $15,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $507
Insurance broker organization code?	3

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

Policy contract number

00404354

Policy instance

Insurance contract or identification number	00404354
Number of Individuals Covered	3
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $405
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $18,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $405
Insurance broker organization code?	3

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

Policy contract number

00358700

Policy instance

Insurance contract or identification number	00358700
Number of Individuals Covered	110
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,418
Total amount of fees paid to insurance company	USD $5,231
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,418
Amount paid for insurance broker fees	5231
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NLT41

Policy instance

Insurance contract or identification number	NLT41
Number of Individuals Covered	22
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,658
Total amount of fees paid to insurance company	USD $557
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $32,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,990
Amount paid for insurance broker fees	398
Insurance broker organization code?	3

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

Policy contract number

SYK600265

Policy instance

Insurance contract or identification number	SYK600265
Number of Individuals Covered	95
Insurance policy start date	2018-06-01
Insurance policy end date	2019-06-01
Total amount of commissions paid to insurance broker	USD $264
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $2,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $264
Insurance broker organization code?	3

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

Policy contract number

SGN600599

Policy instance

Insurance contract or identification number	SGN600599
Number of Individuals Covered	45
Insurance policy start date	2018-06-01
Insurance policy end date	2019-06-01
Total amount of commissions paid to insurance broker	USD $2,460
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,460
Insurance broker organization code?	3

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E3957883

Policy instance

Insurance contract or identification number	E3957883
Number of Individuals Covered	23
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $1,200
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSPITAL CONFINEMENT
Welfare Benefit Premiums Paid to Carrier	USD $16,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $649
Insurance broker organization code?	3

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

Policy contract number

00404354

Policy instance

Insurance contract or identification number	00404354
Number of Individuals Covered	3
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
Welfare Benefit Premiums Paid to Carrier	USD $22,281
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: 00000 )

Policy contract number

13726

Policy instance

Insurance contract or identification number	13726
Number of Individuals Covered	98
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00358700

Policy instance

Insurance contract or identification number	00358700
Number of Individuals Covered	107
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,633
Total amount of fees paid to insurance company	USD $4,768
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,633
Amount paid for insurance broker fees	4768
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NLT41

Policy instance

Insurance contract or identification number	NLT41
Number of Individuals Covered	28
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $8,479
Total amount of fees paid to insurance company	USD $915
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $29,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

SGN600599

Policy instance

Insurance contract or identification number	SGN600599
Number of Individuals Covered	47
Insurance policy start date	2017-06-01
Insurance policy end date	2018-06-01
Total amount of commissions paid to insurance broker	USD $2,146
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

SYK600265

Policy instance

Insurance contract or identification number	SYK600265
Number of Individuals Covered	91
Insurance policy start date	2017-06-01
Insurance policy end date	2018-06-01
Total amount of commissions paid to insurance broker	USD $290
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $2,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00404354

Policy instance

Insurance contract or identification number	00404354
Number of Individuals Covered	3
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
Welfare Benefit Premiums Paid to Carrier	USD $16,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E3957883

Policy instance

Insurance contract or identification number	E3957883
Number of Individuals Covered	30
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $1,352
Total amount of fees paid to insurance company	USD $30
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSPITAL CONFINEMENT
Welfare Benefit Premiums Paid to Carrier	USD $17,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00410347

Policy instance

Insurance contract or identification number	00410347
Number of Individuals Covered	195
Insurance policy start date	2017-06-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $18,963
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $611,698
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00358700

Policy instance

Insurance contract or identification number	00358700
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $3,396
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00358700

Policy instance

Insurance contract or identification number	00358700
Number of Individuals Covered	114
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $4,497
Total amount of fees paid to insurance company	USD $4,687
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $80,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,496
Amount paid for insurance broker fees	4687
Insurance broker organization code?	3

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

Policy contract number

00404354

Policy instance

Insurance contract or identification number	00404354
Number of Individuals Covered	4
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
Welfare Benefit Premiums Paid to Carrier	USD $21,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E3957883

Policy instance

Insurance contract or identification number	E3957883
Number of Individuals Covered	50
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $5,295
Total amount of fees paid to insurance company	USD $799
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSPITAL CONFINEMENT
Welfare Benefit Premiums Paid to Carrier	USD $29,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,439
Amount paid for insurance broker fees	799
Insurance broker organization code?	3

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

Policy contract number

SGN600599

Policy instance

Insurance contract or identification number	SGN600599
Number of Individuals Covered	30
Insurance policy start date	2015-06-01
Insurance policy end date	2016-06-01
Total amount of commissions paid to insurance broker	USD $1,850
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,850
Insurance broker organization code?	3

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

Policy contract number

SYK600265

Policy instance

Insurance contract or identification number	SYK600265
Number of Individuals Covered	85
Insurance policy start date	2015-06-01
Insurance policy end date	2016-06-01
Total amount of commissions paid to insurance broker	USD $220
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $1,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $220
Insurance broker organization code?	3

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

Policy contract number

00410347

Policy instance

Insurance contract or identification number	00410347
Number of Individuals Covered	201
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $31,937
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $967,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,937
Insurance broker organization code?	3

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

Policy contract number

00358700

Policy instance

Insurance contract or identification number	00358700
Number of Individuals Covered	106
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $3,848
Total amount of fees paid to insurance company	USD $4,259
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,769
Amount paid for insurance broker fees	4259
Insurance broker organization code?	3

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

Policy contract number

00404354

Policy instance

Insurance contract or identification number	00404354
Number of Individuals Covered	4
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
Welfare Benefit Premiums Paid to Carrier	USD $13,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E3957883

Policy instance

Insurance contract or identification number	E3957883
Number of Individuals Covered	54
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $6,671
Total amount of fees paid to insurance company	USD $831
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSPITAL CONFINEMENT
Welfare Benefit Premiums Paid to Carrier	USD $33,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,655
Insurance broker organization code?	3
Amount paid for insurance broker fees	831

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

Policy contract number

00410347

Policy instance

Insurance contract or identification number	00410347
Number of Individuals Covered	197
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $31,823
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $99,193
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,823
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3957883

Policy instance

Insurance contract or identification number	E3957883
Number of Individuals Covered	54
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $67
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSPITAL CONFINEMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45
Insurance broker organization code?	3

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

Policy contract number

000400159220

Policy instance

Insurance contract or identification number	000400159220
Number of Individuals Covered	40
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $1,489
Total amount of fees paid to insurance company	USD $298
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,489
Amount paid for insurance broker fees	298
Insurance broker organization code?	3

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

Policy contract number

000010159219

Policy instance

Insurance contract or identification number	000010159219
Number of Individuals Covered	122
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $1,304
Total amount of fees paid to insurance company	USD $335
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,304
Amount paid for insurance broker fees	335
Insurance broker organization code?	3

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

Policy contract number

00358700

Policy instance

Insurance contract or identification number	00358700
Number of Individuals Covered	96
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $2,899
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,885
Insurance broker organization code?	3

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

Policy contract number

00404354

Policy instance

Insurance contract or identification number	00404354
Number of Individuals Covered	4
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
Welfare Benefit Premiums Paid to Carrier	USD $12,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E3957883

Policy instance

Insurance contract or identification number	E3957883
Number of Individuals Covered	37
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $2,480
Total amount of fees paid to insurance company	USD $111
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSPITAL CONFINEMENT
Welfare Benefit Premiums Paid to Carrier	USD $30,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $942
Insurance broker organization code?	3
Amount paid for insurance broker fees	54

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

Policy contract number

00410347

Policy instance

Insurance contract or identification number	00410347
Number of Individuals Covered	184
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $29,314
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $792,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,314
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3957883

Policy instance

Insurance contract or identification number	E3957883
Number of Individuals Covered	54
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $44
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSPITAL CONFINEMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32
Insurance broker organization code?	3

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

Policy contract number

000400159220

Policy instance

Insurance contract or identification number	000400159220
Number of Individuals Covered	37
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $1,513
Total amount of fees paid to insurance company	USD $588
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,513
Amount paid for insurance broker fees	588
Insurance broker organization code?	3

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

Policy contract number

000010159219

Policy instance

Insurance contract or identification number	000010159219
Number of Individuals Covered	112
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $1,142
Total amount of fees paid to insurance company	USD $499
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,142
Amount paid for insurance broker fees	499
Insurance broker organization code?	3

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

Policy contract number

000010159219

Policy instance

Insurance contract or identification number	000010159219
Number of Individuals Covered	103
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $986
Total amount of fees paid to insurance company	USD $239
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $986
Amount paid for insurance broker fees	239
Insurance broker organization code?	3

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

Policy contract number

000400159220

Policy instance

Insurance contract or identification number	000400159220
Number of Individuals Covered	40
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $1,543
Total amount of fees paid to insurance company	USD $309
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,543
Amount paid for insurance broker fees	309
Insurance broker organization code?	3

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

Policy contract number

00410347

Policy instance

Insurance contract or identification number	00410347
Number of Individuals Covered	183
Insurance policy start date	2012-06-02
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $22,969
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $611,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,969
Insurance broker organization code?	3

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

Policy contract number

00358700

Policy instance

Insurance contract or identification number	00358700
Number of Individuals Covered	88
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $2,767
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,729
Insurance broker organization code?	3

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Company Name:	COSTANZO'S BAKERY, LLC
Employer identification number (EIN):	161077221
NAIC Classification:	311800
NAIC Description:	Bakeries and Tortilla Manufacturing