THE ARC JEFFERSON - ST. LAWRENCE has sponsored the creation of one or more 401k plans.
Additional information about THE ARC JEFFERSON - ST. LAWRENCE
Submission information for form 5500 for 401k plan JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN
401k plan membership statisitcs for JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 391 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 472 |
| Total of all active and inactive participants | 2022-01-01 | 472 |
| 2021: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 439 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 391 |
| Total of all active and inactive participants | 2021-01-01 | 391 |
| 2020: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 416 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 439 |
| Total of all active and inactive participants | 2020-01-01 | 439 |
| 2019: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 218 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 416 |
| Total of all active and inactive participants | 2019-01-01 | 416 |
| 2018: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 211 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 218 |
| Total of all active and inactive participants | 2018-01-01 | 218 |
| 2017: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 225 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 211 |
| Total of all active and inactive participants | 2017-01-01 | 211 |
| 2016: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 222 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 225 |
| Total of all active and inactive participants | 2016-01-01 | 225 |
| 2015: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 233 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 222 |
| Total of all active and inactive participants | 2015-01-01 | 222 |
| 2014: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 218 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 233 |
| Total of all active and inactive participants | 2014-01-01 | 233 |
| 2013: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 235 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 218 |
| Total of all active and inactive participants | 2013-01-01 | 218 |
| 2012: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 410 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 235 |
| Total of all active and inactive participants | 2012-01-01 | 235 |
| 2011: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 366 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 410 |
| Total of all active and inactive participants | 2011-01-01 | 410 |
| 2009: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 362 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 368 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 10 |
| Total of all active and inactive participants | 2009-01-01 | 382 |
| Total participants | 2009-01-01 | 382 |
| 2022: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | Yes |
| 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: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: JEFFERSON REHABILITATION CENTER BANK BENEFIT 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: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | Yes |
| 2016-01-01 | 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: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: JEFFERSON REHABILITATION CENTER BANK BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| MVP SELECT CARE, INC. (National Association of Insurance Commissioners NAIC id number: 11125 ) |
| Policy contract number | 490657 |
| Policy instance | 1 |
| Insurance contract or identification number | 490657 | | Number of Individuals Covered | 472 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | 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 | 00122426 |
| Policy instance | 1 |
| Insurance contract or identification number | 00122426 | | Number of Individuals Covered | 391 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $119,838 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $119,838 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00122426 |
| Policy instance | 1 |
| Insurance contract or identification number | 00122426 | | Number of Individuals Covered | 439 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $110,216 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $110,216 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00122426 |
| Policy instance | 1 |
| Insurance contract or identification number | 00122426 | | Number of Individuals Covered | 416 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $105,270 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $105,270 | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 409930-0001 | | Number of Individuals Covered | 217 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $66,868 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,556,356 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $66,868 | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-C001 |
| Policy instance | 2 |
| Insurance contract or identification number | 409930-C001 | | 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 $31 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,251 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31 | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-C001 |
| Policy instance | 2 |
| Insurance contract or identification number | 409930-C001 | | Number of Individuals Covered | 0 | | 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 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $613 | | 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 | 409930-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 409930-0001 | | Number of Individuals Covered | 211 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $66,300 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,559,756 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $66,300 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT SERVICE GROUP, INC. |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 409930-0001 | | Number of Individuals Covered | 222 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $69,328 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,520,668 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $69,328 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT SERVICE GROUP, INC. |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-C001 |
| Policy instance | 2 |
| Insurance contract or identification number | 409930-C001 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $567 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,460 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $567 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT SERVICE GROUP, INC. |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-C001 |
| Policy instance | 2 |
| Insurance contract or identification number | 409930-C001 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $476 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,138 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $476 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT SERVICE GROUP, INC. |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 409930-0001 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $67,555 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,614,152 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $67,555 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT SERVICE GROUP, INC. |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 409930-0001 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $74,118 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,553,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $74,118 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT SERVICE GROUP, INC. |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-C001 |
| Policy instance | 2 |
| Insurance contract or identification number | 409930-C001 | | 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 $779 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,866 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $779 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT SERVICE GROUP, INC. |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 409930-0001 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $64,720 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,521,217 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64,720 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT SERVICE GROUP, INC. |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-C001 |
| Policy instance | 2 |
| Insurance contract or identification number | 409930-C001 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $1,123 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,016 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,123 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT SERVICE GROUP, INC. |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 409930-C001 |
| Policy instance | 2 |
| Insurance contract or identification number | 409930-C001 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $677 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,761 | | 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 | 409930-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 409930-0001 | | Number of Individuals Covered | 410 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $59,372 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,337,935 | | 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 | 403329-002 |
| Policy instance | 2 |
| Insurance contract or identification number | 403329-002 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $24,698 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,698 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT SERVICE GROUP, INC. |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 403328-002 |
| Policy instance | 1 |
| Insurance contract or identification number | 403328-002 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $18,886 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,886 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT SERVICE GROUP, INC. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00389139 |
| Policy instance | 3 |
| Insurance contract or identification number | 00389139 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $7,043 | | Total amount of fees paid to insurance company | USD $5,154 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $142,061 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,974 | | Amount paid for insurance broker fees | 5154 | | Insurance broker organization code? | 3 | | Insurance broker name | CNY AGENCY LLC |
|
