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THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 401k Plan overview

Plan NameTHE SHADOWFAX CORPORATION GROUP INSURANCE PLAN
Plan identification number 503

THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN Benefits

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

401k Sponsoring company profile

THE SHADOWFAX CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:THE SHADOWFAX CORPORATION
Employer identification number (EIN):232368549
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5032022-03-01AMY BRILLINGER2023-06-26
5032021-03-01AMY BRILLINGER2022-09-20
5032020-03-01THERESA A. LINEBAUGH2021-07-27
5032019-03-01THERESA A. LINEBAUGH2020-08-24
5032018-03-01
5032017-03-01
5032016-03-01
5032015-03-01
5032014-03-01
5032013-03-01
5032012-03-01THERESA A. LINEBAUGH
5032011-03-01THERESA A. LINEBAUGH
5032010-03-01THERSA A. LINEBAUGH

Plan Statistics for THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN

401k plan membership statisitcs for THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN

Measure Date Value
2022: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year2022-03-01156
Total number of active participants reported on line 7a of the Form 55002022-03-01146
Number of retired or separated participants receiving benefits2022-03-012
Number of other retired or separated participants entitled to future benefits2022-03-010
Total of all active and inactive participants2022-03-01148
2021: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year2021-03-01175
Total number of active participants reported on line 7a of the Form 55002021-03-01159
Number of retired or separated participants receiving benefits2021-03-011
Number of other retired or separated participants entitled to future benefits2021-03-010
Total of all active and inactive participants2021-03-01160
2020: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year2020-03-01144
Total number of active participants reported on line 7a of the Form 55002020-03-01156
Number of retired or separated participants receiving benefits2020-03-011
Number of other retired or separated participants entitled to future benefits2020-03-010
Total of all active and inactive participants2020-03-01157
2019: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year2019-03-01182
Total number of active participants reported on line 7a of the Form 55002019-03-01191
Number of retired or separated participants receiving benefits2019-03-010
Number of other retired or separated participants entitled to future benefits2019-03-010
Total of all active and inactive participants2019-03-01191
2018: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year2018-03-01152
Total number of active participants reported on line 7a of the Form 55002018-03-01185
Number of retired or separated participants receiving benefits2018-03-010
Number of other retired or separated participants entitled to future benefits2018-03-010
Total of all active and inactive participants2018-03-01185
2017: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year2017-03-01135
Total number of active participants reported on line 7a of the Form 55002017-03-01149
Number of retired or separated participants receiving benefits2017-03-010
Number of other retired or separated participants entitled to future benefits2017-03-010
Total of all active and inactive participants2017-03-01149
2016: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year2016-03-01150
Total number of active participants reported on line 7a of the Form 55002016-03-01132
Number of retired or separated participants receiving benefits2016-03-010
Number of other retired or separated participants entitled to future benefits2016-03-010
Total of all active and inactive participants2016-03-01132
2015: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year2015-03-01154
Total number of active participants reported on line 7a of the Form 55002015-03-01153
Number of retired or separated participants receiving benefits2015-03-010
Number of other retired or separated participants entitled to future benefits2015-03-010
Total of all active and inactive participants2015-03-01153
2014: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year2014-03-01150
Total number of active participants reported on line 7a of the Form 55002014-03-01152
Number of retired or separated participants receiving benefits2014-03-010
Number of other retired or separated participants entitled to future benefits2014-03-010
Total of all active and inactive participants2014-03-01152
2013: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year2013-03-01152
Total number of active participants reported on line 7a of the Form 55002013-03-01156
Number of retired or separated participants receiving benefits2013-03-010
Number of other retired or separated participants entitled to future benefits2013-03-010
Total of all active and inactive participants2013-03-01156
2012: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year2012-03-01149
Total number of active participants reported on line 7a of the Form 55002012-03-01152
Number of retired or separated participants receiving benefits2012-03-010
Number of other retired or separated participants entitled to future benefits2012-03-010
Total of all active and inactive participants2012-03-01152
2011: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year2011-03-01143
Total number of active participants reported on line 7a of the Form 55002011-03-01149
Total of all active and inactive participants2011-03-01149
2010: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2010 401k membership
Total participants, beginning-of-year2010-03-01139
Total number of active participants reported on line 7a of the Form 55002010-03-01143
Total of all active and inactive participants2010-03-01143

Form 5500 Responses for THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN

2022: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2022 form 5500 responses
2022-03-01Type of plan entitySingle employer plan
2022-03-01Submission has been amendedNo
2022-03-01This submission is the final filingNo
2022-03-01This return/report is a short plan year return/report (less than 12 months)No
2022-03-01Plan is a collectively bargained planNo
2022-03-01Plan funding arrangement – InsuranceYes
2022-03-01Plan funding arrangement – General assets of the sponsorYes
2022-03-01Plan benefit arrangement – InsuranceYes
2022-03-01Plan benefit arrangement – General assets of the sponsorYes
2021: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2021 form 5500 responses
2021-03-01Type of plan entitySingle employer plan
2021-03-01Submission has been amendedNo
2021-03-01This submission is the final filingNo
2021-03-01This return/report is a short plan year return/report (less than 12 months)No
2021-03-01Plan is a collectively bargained planNo
2021-03-01Plan funding arrangement – InsuranceYes
2021-03-01Plan funding arrangement – General assets of the sponsorYes
2021-03-01Plan benefit arrangement – InsuranceYes
2021-03-01Plan benefit arrangement – General assets of the sponsorYes
2020: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2020 form 5500 responses
2020-03-01Type of plan entitySingle employer plan
2020-03-01Plan funding arrangement – InsuranceYes
2020-03-01Plan funding arrangement – General assets of the sponsorYes
2020-03-01Plan benefit arrangement – InsuranceYes
2020-03-01Plan benefit arrangement – General assets of the sponsorYes
2019: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2019 form 5500 responses
2019-03-01Type of plan entitySingle employer plan
2019-03-01Plan funding arrangement – InsuranceYes
2019-03-01Plan funding arrangement – General assets of the sponsorYes
2019-03-01Plan benefit arrangement – InsuranceYes
2019-03-01Plan benefit arrangement – General assets of the sponsorYes
2018: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2018 form 5500 responses
2018-03-01Type of plan entitySingle employer plan
2018-03-01Plan funding arrangement – InsuranceYes
2018-03-01Plan funding arrangement – General assets of the sponsorYes
2018-03-01Plan benefit arrangement – InsuranceYes
2018-03-01Plan benefit arrangement – General assets of the sponsorYes
2017: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2017 form 5500 responses
2017-03-01Type of plan entitySingle employer plan
2017-03-01Plan funding arrangement – InsuranceYes
2017-03-01Plan funding arrangement – General assets of the sponsorYes
2017-03-01Plan benefit arrangement – InsuranceYes
2017-03-01Plan benefit arrangement – General assets of the sponsorYes
2016: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2016 form 5500 responses
2016-03-01Type of plan entitySingle employer plan
2016-03-01Plan funding arrangement – InsuranceYes
2016-03-01Plan funding arrangement – General assets of the sponsorYes
2016-03-01Plan benefit arrangement – InsuranceYes
2016-03-01Plan benefit arrangement – General assets of the sponsorYes
2015: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2015 form 5500 responses
2015-03-01Type of plan entitySingle employer plan
2015-03-01Plan funding arrangement – InsuranceYes
2015-03-01Plan funding arrangement – General assets of the sponsorYes
2015-03-01Plan benefit arrangement – InsuranceYes
2015-03-01Plan benefit arrangement – General assets of the sponsorYes
2014: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2014 form 5500 responses
2014-03-01Type of plan entitySingle employer plan
2014-03-01Plan funding arrangement – InsuranceYes
2014-03-01Plan funding arrangement – General assets of the sponsorYes
2014-03-01Plan benefit arrangement – InsuranceYes
2014-03-01Plan benefit arrangement – General assets of the sponsorYes
2013: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2013 form 5500 responses
2013-03-01Type of plan entitySingle employer plan
2013-03-01Plan funding arrangement – InsuranceYes
2013-03-01Plan funding arrangement – General assets of the sponsorYes
2013-03-01Plan benefit arrangement – InsuranceYes
2013-03-01Plan benefit arrangement – General assets of the sponsorYes
2012: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2012 form 5500 responses
2012-03-01Type of plan entitySingle employer plan
2012-03-01Plan funding arrangement – InsuranceYes
2012-03-01Plan funding arrangement – General assets of the sponsorYes
2012-03-01Plan benefit arrangement – InsuranceYes
2012-03-01Plan benefit arrangement – General assets of the sponsorYes
2011: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2011 form 5500 responses
2011-03-01Type of plan entitySingle employer plan
2011-03-01Plan funding arrangement – InsuranceYes
2011-03-01Plan benefit arrangement – InsuranceYes
2010: THE SHADOWFAX CORPORATION GROUP INSURANCE PLAN 2010 form 5500 responses
2010-03-01Type of plan entitySingle employer plan
2010-03-01First time form 5500 has been submittedYes
2010-03-01Plan funding arrangement – InsuranceYes
2010-03-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberVARIOUS
Policy instance 2
Insurance contract or identification numberVARIOUS
Number of Individuals Covered153
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $6,354
Total amount of fees paid to insurance companyUSD $480
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISABILITY
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 CarrierUSD $50,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,354
Insurance broker organization code?3
Amount paid for insurance broker fees480
Additional information about fees paid to insurance brokerFEES
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered135
Insurance policy start date2022-03-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $367
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $367
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered151
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $785
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $785
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberVARIOUS
Policy instance 2
Insurance contract or identification numberVARIOUS
Number of Individuals Covered159
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $4,766
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISABILITY
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 CarrierUSD $35,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,766
Insurance broker organization code?3
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract numberNN00088
Policy instance 2
Insurance contract or identification numberNN00088
Number of Individuals Covered186
Insurance policy start date2020-03-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $3,470
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $28,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,470
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered175
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $452
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $452
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered179
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $849
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $849
Insurance broker organization code?3
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract numberNN00088
Policy instance 3
Insurance contract or identification numberNN00088
Number of Individuals Covered189
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $4,372
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $36,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,372
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number079811
Policy instance 2
Insurance contract or identification number079811
Number of Individuals Covered157
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $53,808
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,283,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $53,808
Insurance broker organization code?3
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract numberNN00088
Policy instance 3
Insurance contract or identification numberNN00088
Number of Individuals Covered182
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $3,984
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $32,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,984
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number079811
Policy instance 2
Insurance contract or identification number079811
Number of Individuals Covered159
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $49,855
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,298,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $49,855
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered179
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $469
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $469
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered142
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $717
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $717
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number079811
Policy instance 2
Insurance contract or identification number079811
Number of Individuals Covered130
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $41,064
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,057,386
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,064
Insurance broker organization code?3
Insurance broker nameALEGRA GROUP INC
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract numberNN0088
Policy instance 3
Insurance contract or identification numberNN0088
Number of Individuals Covered148
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $3,416
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $27,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,416
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract numberBN0088
Policy instance 4
Insurance contract or identification numberBN0088
Number of Individuals Covered150
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $2,661
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $30,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,661
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number4054404
Policy instance 3
Insurance contract or identification number4054404
Number of Individuals Covered44
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $5,592
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $38,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,592
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered140
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $730
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $730
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number079811
Policy instance 2
Insurance contract or identification number079811
Number of Individuals Covered125
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $42,922
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $935,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,922
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract numberBN0088
Policy instance 5
Insurance contract or identification numberBN0088
Number of Individuals Covered151
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $2,285
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $15,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,285
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered147
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $407
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $407
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number079811
Policy instance 2
Insurance contract or identification number079811
Number of Individuals Covered139
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $42,510
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $868,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,510
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberB5647
Policy instance 3
Insurance contract or identification numberB5647
Number of Individuals Covered0
Insurance policy start date2014-03-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $929
Total amount of fees paid to insurance companyUSD $135
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $5,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $340
Amount paid for insurance broker fees88
Additional information about fees paid to insurance brokerFEES, AWARDS, PRIZES, BONUSES OR OTHER FORMS OF NON-MONETARY COMPENSA
Insurance broker organization code?3
Insurance broker nameJEFFREY R STAUFFER
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number4054404
Policy instance 4
Insurance contract or identification number4054404
Number of Individuals Covered49
Insurance policy start date2014-06-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $5,338
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $36,637
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,338
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
HARLEYSVILLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64327 )
Policy contract numberG005007-0001
Policy instance 3
Insurance contract or identification numberG005007-0001
Number of Individuals Covered145
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $1,208
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $6,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $671
Insurance broker organization code?3
Insurance broker nameGETTYSBURG HEALTH ADMIN INC
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number079811
Policy instance 2
Insurance contract or identification number079811
Number of Individuals Covered133
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $42,244
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $812,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,244
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered144
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $727
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $727
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberB5647
Policy instance 4
Insurance contract or identification numberB5647
Number of Individuals Covered23
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $4,251
Total amount of fees paid to insurance companyUSD $34
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $20,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,350
Amount paid for insurance broker fees21
Additional information about fees paid to insurance brokerFEES, AWARDS, PRIZES, BONUSES OR OTHER FORMS OF NON-MONETARY COMPENSA
Insurance broker organization code?3
Insurance broker nameJEFFREY R STAUFFER
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered141
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $340
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $340
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number079811
Policy instance 2
Insurance contract or identification number079811
Number of Individuals Covered123
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $41,418
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $782,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,418
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
HARLEYSVILLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64327 )
Policy contract numberG005007-0001
Policy instance 3
Insurance contract or identification numberG005007-0001
Number of Individuals Covered153
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $1,186
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD & D
Welfare Benefit Premiums Paid to CarrierUSD $6,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $659
Insurance broker organization code?3
Insurance broker nameGETTYSBURG HEALTH ADMIN INC
HARLEYSVILLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64327 )
Policy contract numberG005007-0001
Policy instance 4
Insurance contract or identification numberG005007-0001
Number of Individuals Covered149
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $1,204
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD & D
Welfare Benefit Premiums Paid to CarrierUSD $6,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )
Policy contract number10818
Policy instance 3
Insurance contract or identification number10818
Number of Individuals Covered136
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $1,583
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $36,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number079811
Policy instance 2
Insurance contract or identification number079811
Number of Individuals Covered129
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $43,542
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $818,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered144
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $633
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1133
Policy instance 1
Insurance contract or identification number1133
Number of Individuals Covered129
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $330
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $277
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number079811
Policy instance 2
Insurance contract or identification number079811
Number of Individuals Covered119
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $25,528
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $852,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,376
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )
Policy contract numberPA2387
Policy instance 3
Insurance contract or identification numberPA2387
Number of Individuals Covered126
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $1,407
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $35,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,407
Insurance broker organization code?3
Insurance broker nameTHE GLATFELTER AGENCY, INC.
TEACHERS PROTECTIVE MUTUAL LIFE INSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 69353 )
Policy contract numberGBQ-6040
Policy instance 4
Insurance contract or identification numberGBQ-6040
Number of Individuals Covered121
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $10,085
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedSUPPLEMENTAL GROUP ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $126,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,085
Insurance broker organization code?3
Insurance broker nameAMERICAN INSURANCE ADMINISTRATORS
HARLEYSVILLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64327 )
Policy contract numberG005007-0001
Policy instance 5
Insurance contract or identification numberG005007-0001
Number of Individuals Covered143
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $1,033
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $574
Insurance broker organization code?3
Insurance broker nameBENEFITS DESIGN CONSULTANTS, INC.

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