401k Plan data: THE SKILLS GROUP HEALTH BENEFIT PLAN plan

THE SKILLS GROUP HEALTH BENEFIT PLAN 401k Plan overview

Plan Name	THE SKILLS GROUP HEALTH BENEFIT PLAN
Plan identification number	501

THE SKILLS GROUP HEALTH BENEFIT PLAN Benefits

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

401k Sponsoring company profile

SKILLS OF CENTRAL PENNSYLVANIA, INC. has sponsored the creation of one or more 401k plans.

Company Name: SKILLS OF CENTRAL PENNSYLVANIA, INC.

Employer identification number (EIN): 240855593

NAIC Classification: 624310
NAIC Description: Vocational Rehabilitation Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE SKILLS GROUP HEALTH BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01
501 2021-07-01
501 2020-07-01
501 2019-07-01
501 2018-07-01
501 2017-07-01 LORIE SMITH
501 2016-07-01 ELIZABETH YOUNG
501 2015-07-01 ELIZABETH YOUNG
501 2014-07-01 ELIZABETH YOUNG
501 2013-07-01 ELIZABETH YOUNG
501 2012-07-01 ELIZABETH YOUNG
501 2011-07-01 JOHN FOX
501 2009-07-01 JOHN FOX
501 2009-07-01 JOHN FOX

Plan Statistics for THE SKILLS GROUP HEALTH BENEFIT PLAN

401k plan membership statisitcs for THE SKILLS GROUP HEALTH BENEFIT PLAN

Measure Date Value
2022: THE SKILLS GROUP HEALTH BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 436
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 421
Number of retired or separated participants receiving benefits 2022-07-01 1
Number of other retired or separated participants entitled to future benefits 2022-07-01 0
Total of all active and inactive participants 2022-07-01 422
2021: THE SKILLS GROUP HEALTH BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 517
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 433
Number of retired or separated participants receiving benefits 2021-07-01 0
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 433
2020: THE SKILLS GROUP HEALTH BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 626
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 792
Total of all active and inactive participants 2020-07-01 792
2019: THE SKILLS GROUP HEALTH BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 649
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 626
Total of all active and inactive participants 2019-07-01 626
2018: THE SKILLS GROUP HEALTH BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 631
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 649
Total of all active and inactive participants 2018-07-01 649
2017: THE SKILLS GROUP HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 651
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 631
Total of all active and inactive participants 2017-07-01 631
2016: THE SKILLS GROUP HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 671
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 651
Number of retired or separated participants receiving benefits 2016-07-01 1
Total of all active and inactive participants 2016-07-01 652
2015: THE SKILLS GROUP HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 683
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 671
Total of all active and inactive participants 2015-07-01 671
2014: THE SKILLS GROUP HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 613
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 683
Total of all active and inactive participants 2014-07-01 683
2013: THE SKILLS GROUP HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 602
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 613
Total of all active and inactive participants 2013-07-01 613
2012: THE SKILLS GROUP HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 592
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 602
Total of all active and inactive participants 2012-07-01 602
2011: THE SKILLS GROUP HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 152
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 148
Number of retired or separated participants receiving benefits 2011-07-01 0
Number of other retired or separated participants entitled to future benefits 2011-07-01 0
Total of all active and inactive participants 2011-07-01 148
2009: THE SKILLS GROUP HEALTH BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-07-01 158
Total number of active participants reported on line 7a of the Form 5500 2009-07-01 141
Number of retired or separated participants receiving benefits 2009-07-01 0
Number of other retired or separated participants entitled to future benefits 2009-07-01 0
Total of all active and inactive participants 2009-07-01 141

Measure	Date	Value
2022: THE SKILLS GROUP HEALTH BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	436
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	421
Number of retired or separated participants receiving benefits	2022-07-01	1
Number of other retired or separated participants entitled to future benefits	2022-07-01	0
Total of all active and inactive participants	2022-07-01	422
2021: THE SKILLS GROUP HEALTH BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	517
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	433
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	433
2020: THE SKILLS GROUP HEALTH BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	626
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	792
Total of all active and inactive participants	2020-07-01	792
2019: THE SKILLS GROUP HEALTH BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	649
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	626
Total of all active and inactive participants	2019-07-01	626
2018: THE SKILLS GROUP HEALTH BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	631
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	649
Total of all active and inactive participants	2018-07-01	649
2017: THE SKILLS GROUP HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	651
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	631
Total of all active and inactive participants	2017-07-01	631
2016: THE SKILLS GROUP HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	671
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	651
Number of retired or separated participants receiving benefits	2016-07-01	1
Total of all active and inactive participants	2016-07-01	652
2015: THE SKILLS GROUP HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	683
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	671
Total of all active and inactive participants	2015-07-01	671
2014: THE SKILLS GROUP HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	613
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	683
Total of all active and inactive participants	2014-07-01	683
2013: THE SKILLS GROUP HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	602
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	613
Total of all active and inactive participants	2013-07-01	613
2012: THE SKILLS GROUP HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	592
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	602
Total of all active and inactive participants	2012-07-01	602
2011: THE SKILLS GROUP HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	152
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	148
Number of retired or separated participants receiving benefits	2011-07-01	0
Number of other retired or separated participants entitled to future benefits	2011-07-01	0
Total of all active and inactive participants	2011-07-01	148
2009: THE SKILLS GROUP HEALTH BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-07-01	158
Total number of active participants reported on line 7a of the Form 5500	2009-07-01	141
Number of retired or separated participants receiving benefits	2009-07-01	0
Number of other retired or separated participants entitled to future benefits	2009-07-01	0
Total of all active and inactive participants	2009-07-01	141

Form 5500 Responses for THE SKILLS GROUP HEALTH BENEFIT PLAN

2022: THE SKILLS GROUP HEALTH BENEFIT PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Submission has been amended	No
2022-07-01	This submission is the final filing	No
2022-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-07-01	Plan is a collectively bargained plan	No
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: THE SKILLS GROUP HEALTH BENEFIT PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Submission has been amended	No
2021-07-01	This submission is the final filing	No
2021-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-07-01	Plan is a collectively bargained plan	No
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: THE SKILLS GROUP HEALTH BENEFIT PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2019: THE SKILLS GROUP HEALTH BENEFIT PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2018: THE SKILLS GROUP HEALTH BENEFIT PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: THE SKILLS GROUP HEALTH BENEFIT PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2016: THE SKILLS GROUP HEALTH BENEFIT PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2015: THE SKILLS GROUP HEALTH BENEFIT PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2014: THE SKILLS GROUP HEALTH BENEFIT PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: THE SKILLS GROUP HEALTH BENEFIT PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2012: THE SKILLS GROUP HEALTH BENEFIT PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2011: THE SKILLS GROUP HEALTH BENEFIT PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Submission has been amended	No
2011-07-01	This submission is the final filing	No
2011-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-07-01	Plan is a collectively bargained plan	No
2011-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: THE SKILLS GROUP HEALTH BENEFIT PLAN 2009 form 5500 responses
2009-07-01	Type of plan entity	Single employer plan
2009-07-01	Submission has been amended	No
2009-07-01	This submission is the final filing	No
2009-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-07-01	Plan is a collectively bargained plan	No
2009-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-07-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

GRANULAR INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93521 )

Policy contract number

0000

Policy instance

Insurance contract or identification number	0000
Number of Individuals Covered	411
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $16,609
Total amount of fees paid to insurance company	USD $29,065
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 $415,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,609
Amount paid for insurance broker fees	29065
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

294198

Policy instance

Insurance contract or identification number	294198
Number of Individuals Covered	797
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $6,241
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 $62,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,241
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

71140

Policy instance

Insurance contract or identification number	71140
Number of Individuals Covered	694
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $39,467
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $302,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,467
Insurance broker organization code?	3

BCS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 38245 )

Policy contract number

ESL-30360

Policy instance

Insurance contract or identification number	ESL-30360
Number of Individuals Covered	413
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $32,064
Total amount of fees paid to insurance company	USD $12,024
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 $400,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,032
Amount paid for insurance broker fees	12024
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

SCP 001/COB

Policy instance

Insurance contract or identification number	SCP 001/COB
Number of Individuals Covered	804
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $617
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 $61,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $617
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

16016

Policy instance

Insurance contract or identification number	16016
Number of Individuals Covered	660
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $3,081
Total amount of fees paid to insurance company	USD $1,913
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $61,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,552
Insurance broker organization code?	3
Amount paid for insurance broker fees	1913
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

16017

Policy instance

Insurance contract or identification number	16017
Number of Individuals Covered	292
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $4,565
Total amount of fees paid to insurance company	USD $2,915
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $91,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,086
Amount paid for insurance broker fees	2915
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

16014

Policy instance

Insurance contract or identification number	16014
Number of Individuals Covered	627
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $4,465
Total amount of fees paid to insurance company	USD $1,544
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	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $49,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,298
Insurance broker organization code?	3
Amount paid for insurance broker fees	1544
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

16015

Policy instance

Insurance contract or identification number	16015
Number of Individuals Covered	262
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $5,367
Total amount of fees paid to insurance company	USD $3,364
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 $107,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,533
Amount paid for insurance broker fees	3364
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )

Policy contract number

11419

Policy instance

Insurance contract or identification number	11419
Number of Individuals Covered	1666
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $258,929
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

00519395

Policy instance

Insurance contract or identification number	00519395
Number of Individuals Covered	792
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $35,625
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $7,612,157
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,625
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

910794

Policy instance

Insurance contract or identification number	910794
Number of Individuals Covered	868
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $20,707
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $388,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,707
Insurance broker organization code?	3

CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 )

Policy contract number

00519395

Policy instance

Insurance contract or identification number	00519395
Number of Individuals Covered	626
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $38,025
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $7,142,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,025
Insurance broker organization code?	3

DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )

Policy contract number

11419

Policy instance

Insurance contract or identification number	11419
Number of Individuals Covered	1243
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $219,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

SCP 001/COB

Policy instance

Insurance contract or identification number	SCP 001/COB
Number of Individuals Covered	1179
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $844
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $844
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

911302

Policy instance

Insurance contract or identification number	911302
Number of Individuals Covered	572
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $687,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

910794

Policy instance

Insurance contract or identification number	910794
Number of Individuals Covered	980
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $18,645
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $401,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,645
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

874382G

Policy instance

Insurance contract or identification number	874382G
Number of Individuals Covered	942
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $4,032
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4032
Additional information about fees paid to insurance broker	BONUSES PAID
Insurance broker organization code?	3

DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )

Policy contract number

11419

Policy instance

Insurance contract or identification number	11419
Number of Individuals Covered	1305
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $249,567
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

00519395

Policy instance

Insurance contract or identification number	00519395
Number of Individuals Covered	649
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $39,495
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $6,850,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,495
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

SCP 001/COB

Policy instance

Insurance contract or identification number	SCP 001/COB
Number of Individuals Covered	1222
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $850
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $850
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

911302

Policy instance

Insurance contract or identification number	911302
Number of Individuals Covered	649
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $798,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

910794

Policy instance

Insurance contract or identification number	910794
Number of Individuals Covered	1015
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $18,497
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $377,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,497
Insurance broker organization code?	3

DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )

Policy contract number

11419

Policy instance

Insurance contract or identification number	11419
Number of Individuals Covered	1333
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $290,563
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

00519395

Policy instance

Insurance contract or identification number	00519395
Number of Individuals Covered	631
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $38,780
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $5,915,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,780
Insurance broker organization code?	3
Insurance broker name	HARTMAN EMPLOYEE BENEFITS

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

SCP 001/COB

Policy instance

Insurance contract or identification number	SCP 001/COB
Number of Individuals Covered	1149
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $752
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $752
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

874382G

Policy instance

Insurance contract or identification number	874382G
Number of Individuals Covered	917
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $14,124
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $286,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,124
Insurance broker organization code?	3
Insurance broker name	KEY INSURANCE & BENEFITS SVCS INC

AVALON INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 12358 )

Policy contract number

00519395

Policy instance

Insurance contract or identification number	00519395
Number of Individuals Covered	631
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $934,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

SCP 001/COB

Policy instance

Insurance contract or identification number	SCP 001/COB
Number of Individuals Covered	1226
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $908
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $908
Insurance broker organization code?	3
Insurance broker name	HARTMAN EMPLOYEE BENEFITS

CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 )

Policy contract number

00519395

Policy instance

Insurance contract or identification number	00519395
Number of Individuals Covered	669
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $31,772
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $6,154,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,772
Insurance broker organization code?	3
Insurance broker name	HARTMAN EMPLOYEE BENEFITS

DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )

Policy contract number

11419

Policy instance

Insurance contract or identification number	11419
Number of Individuals Covered	1404
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $32,650
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $281,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	32650
Additional information about fees paid to insurance broker	ADMIN FEE
Insurance broker organization code?	3
Insurance broker name	CONVENTRY HEALTH CARE, INC.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

874382G

Policy instance

Insurance contract or identification number	874382G
Number of Individuals Covered	977
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $16,848
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $313,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,848
Insurance broker organization code?	3
Insurance broker name	FIRST NIAGARA RISK MANAGEMENT INC

CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 )

Policy contract number

00519395

Policy instance

Insurance contract or identification number	00519395
Number of Individuals Covered	682
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $29,012
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $4,793,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,012
Insurance broker organization code?	3
Insurance broker name	HARTMAN EMPLOYEE BENEFITS, INC.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

874382G

Policy instance

Insurance contract or identification number	874382G
Number of Individuals Covered	977
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $18,562
Total amount of fees paid to insurance company	USD $10,991
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $354,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,562
Amount paid for insurance broker fees	10991
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	FIRST NIAGARA RISK MANAGEMENT INC

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

SCP 001/COB

Policy instance

Insurance contract or identification number	SCP 001/COB
Number of Individuals Covered	1243
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $787
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $78,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $787
Insurance broker organization code?	3
Insurance broker name	HARTMAN EMPLOYEE BENEFITS, INC.

DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )

Policy contract number

11419

Policy instance

Insurance contract or identification number	11419
Number of Individuals Covered	783
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $34,581
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $298,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	34581
Additional information about fees paid to insurance broker	ADMIN FEE
Insurance broker organization code?	3
Insurance broker name	CONVENTRY HEALTH CARE, INC.

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

083039

Policy instance

Insurance contract or identification number	083039
Number of Individuals Covered	172
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $26,277
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $655,642
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,277
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK, INC

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

Policy contract number

LK 751175

Policy instance

Insurance contract or identification number	LK 751175
Number of Individuals Covered	911
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $18,864
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $188,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,864
Insurance broker organization code?	3
Insurance broker name	SIMPSON-MCCRADY BENEFITS

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

1803960000

Policy instance

Insurance contract or identification number	1803960000
Number of Individuals Covered	772
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $2,554
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,662,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,554
Insurance broker organization code?	3
Insurance broker name	HARTMAN EMPLOYEE BENEFITS, INC.

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

SCP 001/COB

Policy instance

Insurance contract or identification number	SCP 001/COB
Number of Individuals Covered	1212
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $824
Total amount of fees paid to insurance company	USD $3,706
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $82,356
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $824
Amount paid for insurance broker fees	3706
Additional information about fees paid to insurance broker	INSURANCE FEES
Insurance broker organization code?	3
Insurance broker name	HARTMAN EMPLOYEE BENEFITS, INC.

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

Policy contract number

OK 966375

Policy instance

Insurance contract or identification number	OK 966375
Number of Individuals Covered	979
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $733
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $7,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $733
Insurance broker organization code?	3
Insurance broker name	SIMPSON-MCCRADY BENEFITS

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

Policy contract number

FLX964765

Policy instance

Insurance contract or identification number	FLX964765
Number of Individuals Covered	979
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $13,102
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $131,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,102
Insurance broker organization code?	3
Insurance broker name	SIMPSON-MCCRADY BENEFITS

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

Policy contract number

LK 963334

Policy instance

Insurance contract or identification number	LK 963334
Number of Individuals Covered	911
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $10,517
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,517
Insurance broker organization code?	3
Insurance broker name	SIMPSON-MCCRADY BENEFITS

DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )

Policy contract number

11419

Policy instance

Insurance contract or identification number	11419
Number of Individuals Covered	759
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $32,400
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $279,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	32400
Additional information about fees paid to insurance broker	ADMIN FEE
Insurance broker organization code?	3
Insurance broker name	CONVENTRY HEALTH CARE, INC.

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

Policy contract number

LK 963334

Policy instance

Insurance contract or identification number	LK 963334
Number of Individuals Covered	851
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $8,557
Total amount of fees paid to insurance company	USD $2,239
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,557
Amount paid for insurance broker fees	2239
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3
Insurance broker name	SIMPSON-MCCRADY BENEFITS

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

Policy contract number

LK 751175

Policy instance

Insurance contract or identification number	LK 751175
Number of Individuals Covered	851
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $15,311
Total amount of fees paid to insurance company	USD $2,813
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $153,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,311
Amount paid for insurance broker fees	2813
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3
Insurance broker name	SIMPSON-MCCRADY BENEFITS

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

083039

Policy instance

Insurance contract or identification number	083039
Number of Individuals Covered	173
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $23,632
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $591,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,632
Insurance broker organization code?	3
Insurance broker name	BENEFITS NETWORK, INC

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

Policy contract number

FLX964765

Policy instance

Insurance contract or identification number	FLX964765
Number of Individuals Covered	929
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $11,144
Total amount of fees paid to insurance company	USD $2,295
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $111,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,144
Amount paid for insurance broker fees	2295
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3
Insurance broker name	SIMPSON-MCCRADY BENEFITS

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

1803960000

Policy instance

Insurance contract or identification number	1803960000
Number of Individuals Covered	756
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $23,526
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,459,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,526
Insurance broker organization code?	3
Insurance broker name	HARTMAN EMPLOYEE BENEFITS, INC.

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

SCP 001/COB

Policy instance

Insurance contract or identification number	SCP 001/COB
Number of Individuals Covered	1246
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $818
Total amount of fees paid to insurance company	USD $3,681
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $818
Amount paid for insurance broker fees	3681
Additional information about fees paid to insurance broker	INSURANCE FEES
Insurance broker organization code?	3
Insurance broker name	HARTMAN EMPLOYEE BENEFITS, INC.

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

Policy contract number

OK 966375

Policy instance

Insurance contract or identification number	OK 966375
Number of Individuals Covered	929
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $646
Total amount of fees paid to insurance company	USD $128
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $6,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $646
Amount paid for insurance broker fees	128
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3
Insurance broker name	SIMPSON-MCCRADY BENEFITS

DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )

Policy contract number

11419

Policy instance

Insurance contract or identification number	11419
Number of Individuals Covered	756
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $30,822
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $265,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	30822
Additional information about fees paid to insurance broker	ADMIN FEE
Insurance broker organization code?	3
Insurance broker name	CONVENTRY HEALTH CARE, INC.

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

1803960000

Policy instance

Insurance contract or identification number	1803960000
Number of Individuals Covered	743
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $23,066
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,392,115
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 number

4887

Policy instance

Insurance contract or identification number	4887
Number of Individuals Covered	744
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $293,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

SCP 001/COB

Policy instance

Insurance contract or identification number	SCP 001/COB
Number of Individuals Covered	1230
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $830
Total amount of fees paid to insurance company	USD $3,737
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $83,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

003285 800

Policy instance

Insurance contract or identification number	003285 800
Number of Individuals Covered	158
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $25,685
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $578,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 11994 )

Policy contract number

003285 902

Policy instance

Insurance contract or identification number	003285 902
Number of Individuals Covered	2
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $92
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	POS
Welfare Benefit Premiums Paid to Carrier	USD $2,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

49923

Policy instance

Insurance contract or identification number	49923
Number of Individuals Covered	907
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $38,790
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $390,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

THE SKILLSOURCE GROUP 401(K) PLAN [EIN = 300129320]

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Company Name:	SKILLS OF CENTRAL PENNSYLVANIA, INC.
Employer identification number (EIN):	240855593
NAIC Classification:	624310
NAIC Description:	Vocational Rehabilitation Services