JEP MANAGEMENT, INC. has sponsored the creation of one or more 401k plans.
Additional information about JEP MANAGEMENT, INC.
Submission information for form 5500 for 401k plan JEP MANAGEMENT MASTER WELFARE PLAN
| 2023: JEP MANAGEMENT MASTER WELFARE PLAN 2023 form 5500 responses |
|---|
| 2023-05-01 | Type of plan entity | Single employer plan |
| 2023-05-01 | Submission has been amended | No |
| 2023-05-01 | This submission is the final filing | No |
| 2023-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2023-05-01 | Plan is a collectively bargained plan | Yes |
| 2023-05-01 | Plan funding arrangement – Insurance | Yes |
| 2023-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: JEP MANAGEMENT MASTER WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-05-01 | Type of plan entity | Single employer plan |
| 2022-05-01 | Submission has been amended | No |
| 2022-05-01 | This submission is the final filing | No |
| 2022-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-05-01 | Plan is a collectively bargained plan | Yes |
| 2022-05-01 | Plan funding arrangement – Insurance | Yes |
| 2022-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: JEP MANAGEMENT MASTER WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-05-01 | Type of plan entity | Single employer plan |
| 2021-05-01 | Submission has been amended | No |
| 2021-05-01 | This submission is the final filing | No |
| 2021-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-05-01 | Plan is a collectively bargained plan | Yes |
| 2021-05-01 | Plan funding arrangement – Insurance | Yes |
| 2021-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: JEP MANAGEMENT MASTER WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-05-01 | Type of plan entity | Single employer plan |
| 2020-05-01 | Submission has been amended | No |
| 2020-05-01 | This submission is the final filing | No |
| 2020-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-05-01 | Plan is a collectively bargained plan | Yes |
| 2020-05-01 | Plan funding arrangement – Insurance | Yes |
| 2020-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: JEP MANAGEMENT MASTER WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-05-01 | Type of plan entity | Single employer plan |
| 2019-05-01 | Submission has been amended | No |
| 2019-05-01 | This submission is the final filing | No |
| 2019-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-05-01 | Plan is a collectively bargained plan | No |
| 2019-05-01 | Plan funding arrangement – Insurance | Yes |
| 2019-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: JEP MANAGEMENT MASTER WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-05-01 | Type of plan entity | Single employer plan |
| 2018-05-01 | Submission has been amended | No |
| 2018-05-01 | This submission is the final filing | No |
| 2018-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-05-01 | Plan is a collectively bargained plan | No |
| 2018-05-01 | Plan funding arrangement – Insurance | Yes |
| 2018-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: JEP MANAGEMENT MASTER WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-05-01 | Type of plan entity | Single employer plan |
| 2017-05-01 | Submission has been amended | No |
| 2017-05-01 | This submission is the final filing | No |
| 2017-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-05-01 | Plan is a collectively bargained plan | No |
| 2017-05-01 | Plan funding arrangement – Insurance | Yes |
| 2017-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: JEP MANAGEMENT MASTER WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-05-01 | Type of plan entity | Single employer plan |
| 2016-05-01 | Submission has been amended | No |
| 2016-05-01 | This submission is the final filing | No |
| 2016-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-05-01 | Plan is a collectively bargained plan | No |
| 2016-05-01 | Plan funding arrangement – Insurance | Yes |
| 2016-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: JEP MANAGEMENT MASTER WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-05-01 | Type of plan entity | Single employer plan |
| 2015-05-01 | Submission has been amended | No |
| 2015-05-01 | This submission is the final filing | No |
| 2015-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-05-01 | Plan is a collectively bargained plan | No |
| 2015-05-01 | Plan funding arrangement – Insurance | Yes |
| 2015-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: JEP MANAGEMENT MASTER WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-05-01 | Type of plan entity | Single employer plan |
| 2014-05-01 | Submission has been amended | No |
| 2014-05-01 | This submission is the final filing | No |
| 2014-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-05-01 | Plan is a collectively bargained plan | No |
| 2014-05-01 | Plan funding arrangement – Insurance | Yes |
| 2014-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: JEP MANAGEMENT MASTER WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-05-01 | Type of plan entity | Single employer plan |
| 2013-05-01 | Submission has been amended | No |
| 2013-05-01 | This submission is the final filing | No |
| 2013-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-05-01 | Plan is a collectively bargained plan | No |
| 2013-05-01 | Plan funding arrangement – Insurance | Yes |
| 2013-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: JEP MANAGEMENT MASTER WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-05-01 | Type of plan entity | Single employer plan |
| 2012-05-01 | Submission has been amended | No |
| 2012-05-01 | This submission is the final filing | No |
| 2012-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-05-01 | Plan is a collectively bargained plan | No |
| 2012-05-01 | Plan funding arrangement – Insurance | Yes |
| 2012-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: JEP MANAGEMENT MASTER WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-05-01 | Type of plan entity | Single employer plan |
| 2011-05-01 | Plan funding arrangement – Insurance | Yes |
| 2011-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: JEP MANAGEMENT MASTER WELFARE PLAN 2010 form 5500 responses |
|---|
| 2010-05-01 | Type of plan entity | Single employer plan |
| 2010-05-01 | Plan funding arrangement – Insurance | Yes |
| 2010-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: JEP MANAGEMENT MASTER WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-05-01 | Type of plan entity | Single employer plan |
| 2009-05-01 | Submission has been amended | No |
| 2009-05-01 | This submission is the final filing | No |
| 2009-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-05-01 | Plan is a collectively bargained plan | No |
| 2009-05-01 | Plan funding arrangement – Insurance | Yes |
| 2009-05-01 | Plan benefit arrangement – Insurance | Yes |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 2 |
| Insurance contract or identification number | 42369 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | 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 | | Other welfare benefits provided | BABY YOURSELF, AIR MEDICAL SERVICES | | 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 |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 704138 |
| Policy instance | 10 |
| Insurance contract or identification number | 704138 | | Number of Individuals Covered | 89 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | Total amount of commissions paid to insurance broker | USD $19,522 | | 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 $851,547 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 1 |
| Insurance contract or identification number | 812173 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2023-04-01 | | Insurance policy end date | 2024-03-31 | | Total amount of commissions paid to insurance broker | USD $190 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,304 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 155665* |
| Policy instance | 3 |
| Insurance contract or identification number | GL 155665* | | Number of Individuals Covered | 360 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | Total amount of commissions paid to insurance broker | USD $12,031 | | Total amount of fees paid to insurance company | USD $3,699 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $228,451 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0149566 |
| Policy instance | 4 |
| Insurance contract or identification number | 0149566 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | 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 $333,296 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881,1054802 |
| Policy instance | 5 |
| Insurance contract or identification number | 9719881,1054802 | | Number of Individuals Covered | 500 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | Total amount of commissions paid to insurance broker | USD $2,579 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $25,746 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5958554 |
| Policy instance | 6 |
| Insurance contract or identification number | 5958554 | | Number of Individuals Covered | 633 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $2,254 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $180,850 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 2676598 |
| Policy instance | 7 |
| Insurance contract or identification number | 2676598 | | Number of Individuals Covered | 222 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | Total amount of commissions paid to insurance broker | USD $49,980 | | Total amount of fees paid to insurance company | USD $2,143 | | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 2676598 |
| Policy instance | 8 |
| Insurance contract or identification number | 2676598 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2023-05-01 | | Insurance policy end date | 2024-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $343 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP0009157982 |
| Policy instance | 9 |
| Insurance contract or identification number | GTP0009157982 | | Number of Individuals Covered | 388 | | Insurance policy start date | 2022-11-01 | | Insurance policy end date | 2023-10-31 | | Total amount of commissions paid to insurance broker | USD $539 | | 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 | BUSINESS TRAVEL ACCIDENT | | 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 $2,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 1 |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 2 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 155665* |
| Policy instance | 3 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 5 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5958554 |
| Policy instance | 6 |
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 2676598 |
| Policy instance | 7 |
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 2676598 |
| Policy instance | 8 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0149566 |
| Policy instance | 4 |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 704138 |
| Policy instance | 10 |
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP0009157982 |
| Policy instance | 9 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5958554 |
| Policy instance | 6 |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 2 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 155665* |
| Policy instance | 3 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0149566 |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 1 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 5 |
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 274464 |
| Policy instance | 7 |
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 2676598 |
| Policy instance | 8 |
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 2676598 |
| Policy instance | 9 |
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP0009157982 |
| Policy instance | 10 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 1 |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 2 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 155665* |
| Policy instance | 3 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0149531 |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0149566 |
| Policy instance | 5 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 6 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5958554 |
| Policy instance | 7 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5958554 |
| Policy instance | 10 |
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-031559 |
| Policy instance | 8 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00622205 |
| Policy instance | 7 |
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 16937 |
| Policy instance | 6 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 155665* |
| Policy instance | 5 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 3886 |
| Policy instance | 4 |
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP 9139391B |
| Policy instance | 3 |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 2 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 1 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 9 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 468795 |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 2 |
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-031559 |
| Policy instance | 11 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00622205 |
| Policy instance | 10 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 6082420* |
| Policy instance | 9 |
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 16937 |
| Policy instance | 8 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 155665* |
| Policy instance | 7 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 6 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 3886 |
| Policy instance | 5 |
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP 9139391-A* |
| Policy instance | 4 |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 3 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 2 |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 3 |
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP 9139391-A |
| Policy instance | 4 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 3886 |
| Policy instance | 5 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 6 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 155665* |
| Policy instance | 7 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 468795 |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 2 |
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | V255819 |
| Policy instance | 4 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 7 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 3886 |
| Policy instance | 6 |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 468795 |
| Policy instance | 1 |
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | G255817 |
| Policy instance | 3 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 468795 |
| Policy instance | 1 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 2 |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 3 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 3886 |
| Policy instance | 4 |
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | V255819 |
| Policy instance | 6 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 5 |
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | G255817 |
| Policy instance | 7 |
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP0009139391 |
| Policy instance | 12 |
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | G255817 |
| Policy instance | 11 |
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | V255819 |
| Policy instance | 10 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 9 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL147036 |
| Policy instance | 8 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR204865 |
| Policy instance | 7 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 2 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | US403609 |
| Policy instance | 1 |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 3 |
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 125662 |
| Policy instance | 4 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 3886 |
| Policy instance | 5 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VPL300662 |
| Policy instance | 6 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 2 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB119071 |
| Policy instance | 3 |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 4 |
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 125662 |
| Policy instance | 5 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00457110 |
| Policy instance | 6 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 3886 |
| Policy instance | 7 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VPL300662 |
| Policy instance | 8 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL147036 |
| Policy instance | 10 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR204865 |
| Policy instance | 9 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | US403609 |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 2 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | US403609 |
| Policy instance | 3 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 147036 |
| Policy instance | 4 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VPL 300662 |
| Policy instance | 5 |
| HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 2250190000 |
| Policy instance | 6 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB-119071 |
| Policy instance | 7 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 468795 |
| Policy instance | 8 |
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 00405 |
| Policy instance | 9 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00457110 |
| Policy instance | 10 |
| BLUE CROSS AND BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 11 |
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 125662 |
| Policy instance | 12 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 204865 |
| Policy instance | 13 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 14 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 38860-38905Y |
| Policy instance | 1 |
| EXPRESS SCRIPTS, INC. (National Association of Insurance Commissioners NAIC id number: 60025 ) |
| Policy contract number | KE4-JEP MANAGEM |
| Policy instance | 15 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 38860-38905Y |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 812173 |
| Policy instance | 2 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | US403609 |
| Policy instance | 3 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 147036 |
| Policy instance | 4 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VPL 300662 |
| Policy instance | 5 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0113686 |
| Policy instance | 6 |
| HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 ) |
| Policy contract number | 2250190000 |
| Policy instance | 7 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 677091G |
| Policy instance | 8 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB-119071 |
| Policy instance | 9 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9719881 |
| Policy instance | 10 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 468795 |
| Policy instance | 11 |
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 00405 |
| Policy instance | 12 |
| BLUE CROSS AND BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 42369 |
| Policy instance | 14 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00457110 |
| Policy instance | 13 |
