401k Plan data: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN plan

MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN
Plan identification number	501

MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE 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) Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

MILLER WELDING AND MACHINE COMPANY, INC. has sponsored the creation of one or more 401k plans.

Company Name: MILLER WELDING AND MACHINE COMPANY, INC.

Employer identification number (EIN): 251114804

NAIC Classification: 332300

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-07-01 CATHERINE ELENSKY 2023-01-30
501 2020-07-01 CATHY ELENSKY 2021-11-19
501 2019-07-01 CATHY ELENSKY 2020-11-25
501 2018-07-01 DAVID K. MILLER 2020-01-27
501 2017-07-01 DAVID K. MILLER DAVID K. MILLER 2019-01-21
501 2016-07-01 DAVID K. MILLER DAVID K. MILLER 2018-01-11
501 2015-07-01 DAVID K. MILLER DAVID K. MILLER 2017-01-26
501 2015-07-01 DAVID K. MILLER DAVID K. MILLER 2016-12-22
501 2015-07-01 DAVID K. MILLER DAVID K. MILLER 2017-01-26
501 2015-07-01 DAVID K. MILLER 2017-01-26
501 2014-07-01 DAVID K. MILLER DAVID K. MILLER 2016-01-28
501 2013-07-01 DAVID K. MILLER DAVID K. MILLER 2015-01-29
501 2012-07-01 DAVID K. MILLER DAVID K. MILLER 2014-01-16
501 2011-07-01 DAVID K. MILLER DAVID K. MILLER 2013-01-14
501 2010-07-01 DAVID K. MILLER DAVID K. MILLER 2012-05-12
501 2009-07-01 DAVID MILLER DAVID MILLER 2011-01-26

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-07-01	CATHERINE ELENSKY	2023-01-30
501	2020-07-01	CATHY ELENSKY	2021-11-19
501	2019-07-01	CATHY ELENSKY	2020-11-25
501	2018-07-01	DAVID K. MILLER	2020-01-27
501	2017-07-01	DAVID K. MILLER		DAVID K. MILLER	2019-01-21
501	2016-07-01	DAVID K. MILLER		DAVID K. MILLER	2018-01-11
501	2015-07-01	DAVID K. MILLER		DAVID K. MILLER	2017-01-26
501	2015-07-01	DAVID K. MILLER		DAVID K. MILLER	2016-12-22
501	2015-07-01	DAVID K. MILLER		DAVID K. MILLER	2017-01-26
501	2015-07-01			DAVID K. MILLER	2017-01-26
501	2014-07-01	DAVID K. MILLER		DAVID K. MILLER	2016-01-28
501	2013-07-01	DAVID K. MILLER		DAVID K. MILLER	2015-01-29
501	2012-07-01	DAVID K. MILLER		DAVID K. MILLER	2014-01-16
501	2011-07-01	DAVID K. MILLER		DAVID K. MILLER	2013-01-14
501	2010-07-01	DAVID K. MILLER		DAVID K. MILLER	2012-05-12
501	2009-07-01	DAVID MILLER		DAVID MILLER	2011-01-26

Plan Statistics for MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN

401k plan membership statisitcs for MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN

Measure Date Value
2021: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 373
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 334
Number of retired or separated participants receiving benefits 2021-07-01 1
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 335
2020: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 334
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 298
Number of retired or separated participants receiving benefits 2020-07-01 5
Number of other retired or separated participants entitled to future benefits 2020-07-01 0
Total of all active and inactive participants 2020-07-01 303
2019: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 397
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 329
Number of retired or separated participants receiving benefits 2019-07-01 5
Number of other retired or separated participants entitled to future benefits 2019-07-01 0
Total of all active and inactive participants 2019-07-01 334
2018: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 343
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 396
Number of retired or separated participants receiving benefits 2018-07-01 1
Number of other retired or separated participants entitled to future benefits 2018-07-01 0
Total of all active and inactive participants 2018-07-01 397
2017: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 562
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 658
Total of all active and inactive participants 2017-07-01 658
2016: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 600
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 562
Total of all active and inactive participants 2016-07-01 562
2015: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 723
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 600
Total of all active and inactive participants 2015-07-01 600
2014: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 683
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 723
Total of all active and inactive participants 2014-07-01 723
2013: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 635
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 683
Total of all active and inactive participants 2013-07-01 683
2012: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 667
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 635
Total of all active and inactive participants 2012-07-01 635
2011: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 384
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 667
Total of all active and inactive participants 2011-07-01 667
2010: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-07-01 262
Total number of active participants reported on line 7a of the Form 5500 2010-07-01 384
Total of all active and inactive participants 2010-07-01 384
2009: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-07-01 291
Total number of active participants reported on line 7a of the Form 5500 2009-07-01 262
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 2009-07-01 262
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-07-01 0
Total participants 2009-07-01 262

Measure	Date	Value
2021: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	373
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	334
Number of retired or separated participants receiving benefits	2021-07-01	1
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	335
2020: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	334
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	298
Number of retired or separated participants receiving benefits	2020-07-01	5
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	303
2019: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	397
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	329
Number of retired or separated participants receiving benefits	2019-07-01	5
Number of other retired or separated participants entitled to future benefits	2019-07-01	0
Total of all active and inactive participants	2019-07-01	334
2018: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	343
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	396
Number of retired or separated participants receiving benefits	2018-07-01	1
Number of other retired or separated participants entitled to future benefits	2018-07-01	0
Total of all active and inactive participants	2018-07-01	397
2017: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	562
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	658
Total of all active and inactive participants	2017-07-01	658
2016: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	600
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	562
Total of all active and inactive participants	2016-07-01	562
2015: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	723
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	600
Total of all active and inactive participants	2015-07-01	600
2014: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	683
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	723
Total of all active and inactive participants	2014-07-01	723
2013: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	635
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	683
Total of all active and inactive participants	2013-07-01	683
2012: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	667
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	635
Total of all active and inactive participants	2012-07-01	635
2011: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	384
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	667
Total of all active and inactive participants	2011-07-01	667
2010: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-07-01	262
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	384
Total of all active and inactive participants	2010-07-01	384
2009: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-07-01	291
Total number of active participants reported on line 7a of the Form 5500	2009-07-01	262
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	262
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-07-01	0
Total participants	2009-07-01	262

Form 5500 Responses for MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN

2021: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE 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 benefit arrangement – Insurance	Yes
2020: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Submission has been amended	No
2020-07-01	This submission is the final filing	No
2020-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-07-01	Plan is a collectively bargained plan	No
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2019: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Submission has been amended	No
2019-07-01	This submission is the final filing	No
2019-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-07-01	Plan is a collectively bargained plan	No
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2018: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Submission has been amended	No
2018-07-01	This submission is the final filing	No
2018-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-07-01	Plan is a collectively bargained plan	No
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE 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: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE 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: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE 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: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE 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: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE 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: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE 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: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2010: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE PLAN 2010 form 5500 responses
2010-07-01	Type of plan entity	Single employer plan
2010-07-01	Plan funding arrangement – Insurance	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes
2009: MILLER WELDING & MACHINE COMPANY HEALTH AND WELFARE 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 – Insurance	Yes
2009-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

275703

Policy instance

Insurance contract or identification number	275703
Number of Individuals Covered	592
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
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 $2,889,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00562706

Policy instance

Insurance contract or identification number	00562706
Number of Individuals Covered	334
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
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	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, OPT LIFE, OPT AD&D, ACCIDENT, CANCER, VOL CRITICAL ILLNESS, VOL HOSPITAL INDEMNITY
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 $310,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

562706

Policy instance

Insurance contract or identification number	562706
Number of Individuals Covered	300
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
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	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, ACCIDENT, CRITICAL ILLNESS,AND HOSPITAL INDEMNITY
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 $255,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

10408800 ET

Policy instance

Insurance contract or identification number	10408800 ET
Number of Individuals Covered	579
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
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 $2,736,173
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
Insurance broker organization code?	3

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

Policy contract number

562706

Policy instance

Insurance contract or identification number	562706
Number of Individuals Covered	329
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
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	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, ACCIDENT, CRITICAL ILLNESS,AND HOSPITAL INDEMNITY
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 $347,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

10408800 ET

Policy instance

Insurance contract or identification number	10408800 ET
Number of Individuals Covered	613
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
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 $2,863,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

VARIOUS

Policy instance

Insurance contract or identification number	VARIOUS
Number of Individuals Covered	698
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
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 $2,683,201
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
Insurance broker organization code?	3

UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 )

Policy contract number

VARIOUS

Policy instance

Insurance contract or identification number	VARIOUS
Number of Individuals Covered	523
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $12,718
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 $127,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,718
Insurance broker organization code?	3

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

3165

Policy instance

Insurance contract or identification number	3165
Number of Individuals Covered	268
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $1,552
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,024
Insurance broker organization code?	3

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA3-830-510595

Policy instance

Insurance contract or identification number	SA3-830-510595
Number of Individuals Covered	396
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $1,913
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $8,167
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,913
Insurance broker organization code?	3

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GD3-830-510595

Policy instance

Insurance contract or identification number	GD3-830-510595
Number of Individuals Covered	396
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $10,014
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 $53,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,014
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

JR592

Policy instance

Insurance contract or identification number	JR592
Number of Individuals Covered	142
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $24,693
Total amount of fees paid to insurance company	USD $682
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, AND HOSPITAL INDEMNITY
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 $107,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,693
Amount paid for insurance broker fees	682
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

LMB94

Policy instance

Insurance contract or identification number	LMB94
Number of Individuals Covered	27
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $4,732
Total amount of fees paid to insurance company	USD $92
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, AND HOSPITAL INDEMNITY
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $26,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,732
Amount paid for insurance broker fees	92
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

00468943

Policy instance

Insurance contract or identification number	00468943
Number of Individuals Covered	233
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $9,099
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $109,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

3165

Policy instance

Insurance contract or identification number	3165
Number of Individuals Covered	232
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,337
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GD3-830-510595-

Policy instance

Insurance contract or identification number	GD3-830-510595-
Number of Individuals Covered	342
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $3,709
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408313

Policy instance

Insurance contract or identification number	010408313
Number of Individuals Covered	3
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 $11,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408800

Policy instance

Insurance contract or identification number	010408800
Number of Individuals Covered	544
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 $2,398,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408801

Policy instance

Insurance contract or identification number	010408801
Number of Individuals Covered	79
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 $305,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408802

Policy instance

Insurance contract or identification number	010408802
Number of Individuals Covered	27
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 $103,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408912

Policy instance

Insurance contract or identification number	010408912
Number of Individuals Covered	5
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 $14,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

01048910

Policy instance

Insurance contract or identification number	01048910
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

01048311

Policy instance

Insurance contract or identification number	01048311
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408909

Policy instance

Insurance contract or identification number	010408909
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 $0
Welfare Benefit Premiums Paid to Carrier	USD $5,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408310

Policy instance

Insurance contract or identification number	010408310
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408911

Policy instance

Insurance contract or identification number	010408911
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408308

Policy instance

Insurance contract or identification number	010408308
Number of Individuals Covered	600
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 $0
Welfare Benefit Premiums Paid to Carrier	USD $2,523,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408309

Policy instance

Insurance contract or identification number	010408309
Number of Individuals Covered	105
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 $0
Welfare Benefit Premiums Paid to Carrier	USD $413,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408312

Policy instance

Insurance contract or identification number	010408312
Number of Individuals Covered	12
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 $0
Welfare Benefit Premiums Paid to Carrier	USD $56,018
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

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

Policy contract number

00468943

Policy instance

Insurance contract or identification number	00468943
Number of Individuals Covered	239
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $10,144
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $125,291
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,265
Insurance broker organization code?	3
Insurance broker name	GILBERT'S INSURANCE AGCY INC

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

3165

Policy instance

Insurance contract or identification number	3165
Number of Individuals Covered	239
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $1,442
Total amount of fees paid to insurance company	USD $2,882
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,442
Amount paid for insurance broker fees	2882
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	GILBERT'S INSURANCE AGCY INC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

BV0230

Policy instance

Insurance contract or identification number	BV0230
Number of Individuals Covered	380
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $11,645
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,645
Insurance broker organization code?	3
Insurance broker name	ANDREW F RODGERS AGENCY INC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

BV0230

Policy instance

Insurance contract or identification number	BV0230
Number of Individuals Covered	380
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $1,597
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,597
Insurance broker organization code?	3
Insurance broker name	ANDREW F RODGERS AGENCY INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408908

Policy instance

Insurance contract or identification number	010408908
Number of Individuals Covered	15
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 $0
Welfare Benefit Premiums Paid to Carrier	USD $47,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

3165

Policy instance

Insurance contract or identification number	3165
Number of Individuals Covered	284
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $1,596
Total amount of fees paid to insurance company	USD $10,428
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 $31,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7235
Additional information about fees paid to insurance broker	RISKS OR OTHER CONTINGENCIES
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $1,596
Insurance broker name	GILBERT'S INSURANCE AGENCY

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

BV0230

Policy instance

Insurance contract or identification number	BV0230
Number of Individuals Covered	454
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $1,615
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 $10,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,615
Insurance broker organization code?	3
Insurance broker name	ANDREW F RODGERS AGENCY INC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

BV0230

Policy instance

Insurance contract or identification number	BV0230
Number of Individuals Covered	454
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $16,039
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 $105,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,039
Insurance broker organization code?	3
Insurance broker name	ANDREW F RODGERS AGENCY INC

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

Policy contract number

00468943

Policy instance

Insurance contract or identification number	00468943
Number of Individuals Covered	274
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $7,391
Total amount of fees paid to insurance company	USD $3,465
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 $133,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,894
Amount paid for insurance broker fees	3465
Insurance broker organization code?	3
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408911

Policy instance

Insurance contract or identification number	010408911
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408310

Policy instance

Insurance contract or identification number	010408310
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408909

Policy instance

Insurance contract or identification number	010408909
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408311

Policy instance

Insurance contract or identification number	010408311
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 $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	WELLNESS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408910

Policy instance

Insurance contract or identification number	010408910
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408308

Policy instance

Insurance contract or identification number	010408308
Number of Individuals Covered	723
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 $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 $2,973,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408309

Policy instance

Insurance contract or identification number	010408309
Number of Individuals Covered	116
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 $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 $494,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408312

Policy instance

Insurance contract or identification number	010408312
Number of Individuals Covered	12
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 $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 $50,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408908

Policy instance

Insurance contract or identification number	010408908
Number of Individuals Covered	3
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 $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 $24,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	ARMS INSURANCE GROUP

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408310

Policy instance

Insurance contract or identification number	010408310
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408909

Policy instance

Insurance contract or identification number	010408909
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408311

Policy instance

Insurance contract or identification number	010408311
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 $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	WELLNESS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408910

Policy instance

Insurance contract or identification number	010408910
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

HARLEYSVILLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64327 )

Policy contract number

G001510-0001

Policy instance

Insurance contract or identification number	G001510-0001
Number of Individuals Covered	358
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $5,287
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 $42,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,287
Insurance broker name	ANDREW F RODGERS INC AGENCY INC

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408308

Policy instance

Insurance contract or identification number	010408308
Number of Individuals Covered	683
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $40,515
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 $2,610,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,515
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408911

Policy instance

Insurance contract or identification number	010408911
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408309

Policy instance

Insurance contract or identification number	010408309
Number of Individuals Covered	101
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $7,534
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 $378,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,534
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

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

Policy contract number

00468943

Policy instance

Insurance contract or identification number	00468943
Number of Individuals Covered	249
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $3,655
Total amount of fees paid to insurance company	USD $4,459
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 $110,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,655
Amount paid for insurance broker fees	4459
Insurance broker organization code?	3
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

3165

Policy instance

Insurance contract or identification number	3165
Number of Individuals Covered	254
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $1,381
Total amount of fees paid to insurance company	USD $2,764
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 $27,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,381
Amount paid for insurance broker fees	1382
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICE FEES
Insurance broker organization code?	3
Insurance broker name

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408908

Policy instance

Insurance contract or identification number	010408908
Number of Individuals Covered	4
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $404
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 $23,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $404
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )

Policy contract number

010408312

Policy instance

Insurance contract or identification number	010408312
Number of Individuals Covered	14
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $877
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 $55,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $877
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

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

Policy contract number

010408911

Policy instance

Insurance contract or identification number	010408911
Number of Individuals Covered	0
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

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

Policy contract number

010408310

Policy instance

Insurance contract or identification number	010408310
Number of Individuals Covered	0
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

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

Policy contract number

010408311

Policy instance

Insurance contract or identification number	010408311
Number of Individuals Covered	0
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 $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	WELLNESS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

3165

Policy instance

Insurance contract or identification number	3165
Number of Individuals Covered	222
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,187
Total amount of fees paid to insurance company	USD $3,087
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 $23,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,187
Amount paid for insurance broker fees	1662
Additional information about fees paid to insurance broker	ADMIN SERVICE FEES
Insurance broker organization code?	3
Insurance broker name

HARLEYSVILLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64327 )

Policy contract number

G001510-0002

Policy instance

Insurance contract or identification number	G001510-0002
Number of Individuals Covered	55
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $885
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 $5,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $885
Insurance broker name	ANDREW F RODGERS INC AGENCY INC

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

Policy contract number

00468943

Policy instance

Insurance contract or identification number	00468943
Number of Individuals Covered	218
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,362
Total amount of fees paid to insurance company	USD $5,731
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 $90,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,362
Amount paid for insurance broker fees	5731
Insurance broker organization code?	3
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

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

Policy contract number

010408908

Policy instance

Insurance contract or identification number	010408908
Number of Individuals Covered	1
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 $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 $5,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

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

Policy contract number

010408312

Policy instance

Insurance contract or identification number	010408312
Number of Individuals Covered	14
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 $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 $47,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

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

Policy contract number

010408309

Policy instance

Insurance contract or identification number	010408309
Number of Individuals Covered	96
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 $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 $291,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

HARLEYSVILLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64327 )

Policy contract number

G001510-0001

Policy instance

Insurance contract or identification number	G001510-0001
Number of Individuals Covered	330
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $5,985
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 $43,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,985
Insurance broker name	ANDREW F RODGERS INC AGENCY INC

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

Policy contract number

010408909

Policy instance

Insurance contract or identification number	010408909
Number of Individuals Covered	0
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 $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 $1,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

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

Policy contract number

010408308

Policy instance

Insurance contract or identification number	010408308
Number of Individuals Covered	635
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 $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 $2,166,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

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

Policy contract number

010408910

Policy instance

Insurance contract or identification number	010408910
Number of Individuals Covered	0
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 $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	FIRST COMMONWEALTH INSURANCE AGENCY

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

3165

Policy instance

Insurance contract or identification number	3165
Number of Individuals Covered	202
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $1,111
Total amount of fees paid to insurance company	USD $1,555
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 $22,213
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

010408308

Policy instance

Insurance contract or identification number	010408308
Number of Individuals Covered	667
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,386,935
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

010408911

Policy instance

Insurance contract or identification number	010408911
Number of Individuals Covered	0
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
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

010408310

Policy instance

Insurance contract or identification number	010408310
Number of Individuals Covered	0
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
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

010408909

Policy instance

Insurance contract or identification number	010408909
Number of Individuals Covered	1
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
Welfare Benefit Premiums Paid to Carrier	USD $3,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95216 )

Policy contract number

010408311

Policy instance

Insurance contract or identification number	010408311
Number of Individuals Covered	0
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
Other welfare benefits provided	WELLNESS
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

010408910

Policy instance

Insurance contract or identification number	010408910
Number of Individuals Covered	0
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
Welfare Benefit Premiums Paid to Carrier	USD $587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARLEYSVILLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64327 )

Policy contract number

G001510-0002

Policy instance

Insurance contract or identification number	G001510-0002
Number of Individuals Covered	47
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $152
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 $1,015
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

010408908

Policy instance

Insurance contract or identification number	010408908
Number of Individuals Covered	2
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,095
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

010408312

Policy instance

Insurance contract or identification number	010408312
Number of Individuals Covered	15
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,123
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00468943

Policy instance

Insurance contract or identification number	00468943
Number of Individuals Covered	197
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $3,223
Total amount of fees paid to insurance company	USD $1,848
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 $81,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARLEYSVILLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64327 )

Policy contract number

G001510-0001

Policy instance

Insurance contract or identification number	G001510-0001
Number of Individuals Covered	362
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $4,488
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 $31,641
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

010408309

Policy instance

Insurance contract or identification number	010408309
Number of Individuals Covered	67
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $226,305
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

010408300

Policy instance

Insurance contract or identification number	010408300
Number of Individuals Covered	196
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $25,863
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 $862,100
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

010408301

Policy instance

Insurance contract or identification number	010408301
Number of Individuals Covered	384
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $41,787
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
Welfare Benefit Premiums Paid to Carrier	USD $1,392,914
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

010408303

Policy instance

Insurance contract or identification number	010408303
Number of Individuals Covered	69
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $6,432
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 $214,386
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

010408900

Policy instance

Insurance contract or identification number	010408900
Number of Individuals Covered	1
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $661
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 $22,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UPMC HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95216 )

Policy contract number

010408001

Policy instance

Insurance contract or identification number	010408001
Number of Individuals Covered	5
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
Other welfare benefits provided	WELLNESS
Welfare Benefit Premiums Paid to Carrier	USD $72
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

010408904

Policy instance

Insurance contract or identification number	010408904
Number of Individuals Covered	1
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $186
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 $6,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARLEYSVILLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64327 )

Policy contract number

G001510-0001

Policy instance

Insurance contract or identification number	G001510-0001
Number of Individuals Covered	266
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $2,998
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 $20,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

MILLER WELDING SUPPLY COMPANY PROFIT SHARING RETIREMENT PLAN [EIN = 381255720]

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Company Name:	MILLER WELDING AND MACHINE COMPANY, INC.
Employer identification number (EIN):	251114804
NAIC Classification:	332300