PITTSBURGH ASSOCIATES has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PITTSBURGH ASSOCIATES WELFARE BENEFITS PLAN
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 01714145, 46 |
| Policy instance | 3 |
| Insurance contract or identification number | 01714145, 46 | | Number of Individuals Covered | 263 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,835 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $41,545 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,835 | | Insurance broker organization code? | 3 |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000470170 |
| Policy instance | 8 |
| Insurance contract or identification number | 000000470170 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $58,295 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000470169 |
| Policy instance | 7 |
| Insurance contract or identification number | 000000470169 | | Number of Individuals Covered | 337 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $149,452 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | R0635532 |
| Policy instance | 6 |
| Insurance contract or identification number | R0635532 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $14 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $286 | | 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 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0635532 |
| Policy instance | 5 |
| Insurance contract or identification number | R0635532 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $317 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $3,402 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $307 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010983666 |
| Policy instance | 4 |
| Insurance contract or identification number | 0010983666 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $29 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $858 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 843582-000,-099 |
| Policy instance | 2 |
| Insurance contract or identification number | 843582-000,-099 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,366 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $178,861 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,366 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 845087-000,-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 845087-000,-099 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $294 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,507 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $294 | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 01714145, 46 |
| Policy instance | 3 |
| Insurance contract or identification number | 01714145, 46 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,715 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,150 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,715 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 843582-000,-099 |
| Policy instance | 2 |
| Insurance contract or identification number | 843582-000,-099 | | Number of Individuals Covered | 286 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $8,791 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $160,272 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,791 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 845087-000,-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 845087-000,-099 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $194 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,238 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $194 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010983666 |
| Policy instance | 4 |
| Insurance contract or identification number | 0010983666 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $82 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,924 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0635532 |
| Policy instance | 5 |
| Insurance contract or identification number | R0635532 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $479 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $6,474 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $424 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000470169 |
| Policy instance | 7 |
| Insurance contract or identification number | 000000470169 | | Number of Individuals Covered | 311 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $150,215 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000470170 |
| Policy instance | 8 |
| Insurance contract or identification number | 000000470170 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $58,266 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | R0635532 |
| Policy instance | 6 |
| Insurance contract or identification number | R0635532 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $17 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $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 | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 01714145, 46 |
| Policy instance | 3 |
| Insurance contract or identification number | 01714145, 46 | | Number of Individuals Covered | 239 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,059 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,475 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,059 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010983666 |
| Policy instance | 4 |
| Insurance contract or identification number | 0010983666 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $179 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,273 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $121 | | Insurance broker organization code? | 3 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | R0635532 |
| Policy instance | 6 |
| Insurance contract or identification number | R0635532 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $16 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $312 | | 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 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000470169 |
| Policy instance | 7 |
| Insurance contract or identification number | 000000470169 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $149,140 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000470170 |
| Policy instance | 8 |
| Insurance contract or identification number | 000000470170 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $61,534 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0635532 |
| Policy instance | 5 |
| Insurance contract or identification number | R0635532 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $1,311 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $9,892 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,124 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 843582-000,-099 |
| Policy instance | 2 |
| Insurance contract or identification number | 843582-000,-099 | | Number of Individuals Covered | 287 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $8,550 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $169,029 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,550 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 845087-000,-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 845087-000,-099 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $209 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,517 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $209 | | Insurance broker organization code? | 3 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | R0635532 |
| Policy instance | 6 |
| Insurance contract or identification number | R0635532 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $16 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $312 | | 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 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000470170 |
| Policy instance | 8 |
| Insurance contract or identification number | 000000470170 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $55,931 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0635532 |
| Policy instance | 5 |
| Insurance contract or identification number | R0635532 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $812 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $9,190 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $565 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010983666 |
| Policy instance | 4 |
| Insurance contract or identification number | 0010983666 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $573 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,636 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $389 | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 01714145, 46 |
| Policy instance | 3 |
| Insurance contract or identification number | 01714145, 46 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,932 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,588 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,932 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 843582-000,-099 |
| Policy instance | 2 |
| Insurance contract or identification number | 843582-000,-099 | | Number of Individuals Covered | 273 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $8,528 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $156,213 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,528 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 845087-000,-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 845087-000,-099 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $206 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,301 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $206 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000470169 |
| Policy instance | 7 |
| Insurance contract or identification number | 000000470169 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $155,415 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0635532 |
| Policy instance | 5 |
| Insurance contract or identification number | R0635532 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $4,954 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $14,140 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,384 | | Insurance broker organization code? | 3 | | Insurance broker name | SMITH, THOMAS, CHRISTOPHER |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | R0635532 |
| Policy instance | 6 |
| Insurance contract or identification number | R0635532 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $266 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $780 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $186 | | Insurance broker organization code? | 3 | | Insurance broker name | SMITH, THOMAS, CHRISTOPHER |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010983666 |
| Policy instance | 4 |
| Insurance contract or identification number | 0010983666 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $3,120 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,102 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,137 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | SMITH, THOMAS, CHRISTOPHER |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 843582-000,-099 |
| Policy instance | 2 |
| Insurance contract or identification number | 843582-000,-099 | | Number of Individuals Covered | 295 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $9,778 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $178,902 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,778 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0635532 |
| Policy instance | 9 |
| Insurance contract or identification number | R0635532 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2016-12-31 | | Insurance policy end date | 2017-12-30 | | Total amount of commissions paid to insurance broker | USD $4,939 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $14,192 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,373 | | Insurance broker organization code? | 3 | | Insurance broker name | SMITH, THOMAS, CHRISTOPHER |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 845087-000,-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 845087-000,-099 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $187 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,238 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $187 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 01714145, 46 |
| Policy instance | 3 |
| Insurance contract or identification number | 01714145, 46 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $3,952 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,516 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,952 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000470170 |
| Policy instance | 8 |
| Insurance contract or identification number | 000000470170 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $40,787 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000470169 |
| Policy instance | 7 |
| Insurance contract or identification number | 000000470169 | | Number of Individuals Covered | 323 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $127,330 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TM05913220 |
| Policy instance | 6 |
| Insurance contract or identification number | TM05913220 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $4,527 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $111,543 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,527 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 01714145, 46 |
| Policy instance | 5 |
| Insurance contract or identification number | 01714145, 46 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,988 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,909 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,988 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7874100 |
| Policy instance | 4 |
| Insurance contract or identification number | E7874100 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,841 | | Total amount of fees paid to insurance company | USD $114 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $778 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | CHAD FISHER |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 845087-000,-099 |
| Policy instance | 2 |
| Insurance contract or identification number | 845087-000,-099 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $221 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,825 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $221 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G#0072573 |
| Policy instance | 1 |
| Insurance contract or identification number | G#0072573 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $3,535 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,224 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,535 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 843582-000,-099 |
| Policy instance | 3 |
| Insurance contract or identification number | 843582-000,-099 | | Number of Individuals Covered | 276 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $8,987 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $178,311 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,987 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G#0072573 |
| Policy instance | 1 |
| Insurance contract or identification number | G#0072573 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $3,446 | | 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 $22,616 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,446 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 215072 |
| Policy instance | 2 |
| Insurance contract or identification number | 215072 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2015-01-01 | | Total amount of commissions paid to insurance broker | USD $1 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,015 | | 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 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 845087-000,-099 |
| Policy instance | 3 |
| Insurance contract or identification number | 845087-000,-099 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $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 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,015 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $432 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 843582-000,-099 |
| Policy instance | 4 |
| Insurance contract or identification number | 843582-000,-099 | | Number of Individuals Covered | 270 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $8,593 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $172,095 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,593 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TM05913220 |
| Policy instance | 7 |
| Insurance contract or identification number | TM05913220 | | Number of Individuals Covered | 287 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $7,180 | | 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 | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $103,319 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,180 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 1930155 |
| Policy instance | 8 |
| Insurance contract or identification number | 1930155 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | 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 organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7874100 |
| Policy instance | 5 |
| Insurance contract or identification number | E7874100 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,290 | | Total amount of fees paid to insurance company | USD $99 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,086 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $347 | | Amount paid for insurance broker fees | 63 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST WORKSITE MARKETING CORP |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 4935702,03,70,7 |
| Policy instance | 6 |
| Insurance contract or identification number | 4935702,03,70,7 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | 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 | | 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 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G# 72573 |
| Policy instance | 1 |
| Insurance contract or identification number | G# 72573 | | Number of Individuals Covered | 66 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,146 | | 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 $20,698 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,146 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 1930155 |
| Policy instance | 8 |
| Insurance contract or identification number | 1930155 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | 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 organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | FHM913078-0 |
| Policy instance | 7 |
| Insurance contract or identification number | FHM913078-0 | | Number of Individuals Covered | 282 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $2,632 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $37,710 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,632 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 4935702,03,70,7 |
| Policy instance | 6 |
| Insurance contract or identification number | 4935702,03,70,7 | | Number of Individuals Covered | 222 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,222 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 845087-000,-099 |
| Policy instance | 3 |
| Insurance contract or identification number | 845087-000,-099 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $557 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,062 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $557 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7874100 |
| Policy instance | 5 |
| Insurance contract or identification number | E7874100 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $1,223 | | Total amount of fees paid to insurance company | USD $72 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,630 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $521 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | TIMOTHY SLATER |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 843582-000,-099 |
| Policy instance | 4 |
| Insurance contract or identification number | 843582-000,-099 | | Number of Individuals Covered | 271 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $8,399 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $167,392 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,399 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 215072 |
| Policy instance | 2 |
| Insurance contract or identification number | 215072 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $4,763 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $64,665 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,763 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 215072 |
| Policy instance | 2 |
| Insurance contract or identification number | 215072 | | Number of Individuals Covered | 263 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2013-01-01 | | Total amount of commissions paid to insurance broker | USD $4,637 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,244 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,637 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 4935700 4935770 |
| Policy instance | 9 |
| Insurance contract or identification number | 4935700 4935770 | | Number of Individuals Covered | 225 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $76,247 | | 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 | | Commission paid to Insurance Broker | USD $76,247 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 1930155 |
| Policy instance | 8 |
| Insurance contract or identification number | 1930155 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | 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 organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | FHM913078-0 |
| Policy instance | 7 |
| Insurance contract or identification number | FHM913078-0 | | Number of Individuals Covered | 285 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,714 | | 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 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $40,043 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,714 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PIT-001,COB |
| Policy instance | 6 |
| Insurance contract or identification number | PIT-001,COB | | Number of Individuals Covered | 221 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,214 | | Total amount of fees paid to insurance company | USD $996 | | 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 $22,141 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,214 | | Amount paid for insurance broker fees | 996 | | Additional information about fees paid to insurance broker | NON-CASH INCENTIVES | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7874100 |
| Policy instance | 5 |
| Insurance contract or identification number | E7874100 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $1,426 | | Total amount of fees paid to insurance company | USD $154 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,373 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $374 | | Amount paid for insurance broker fees | 83 | | Additional information about fees paid to insurance broker | NON-CASH INCENTIVES | | Insurance broker organization code? | 3 | | Insurance broker name | BRYAN M. TATE |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 843582-000,-099 |
| Policy instance | 4 |
| Insurance contract or identification number | 843582-000,-099 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $8,539 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $170,995 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,539 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 845087-000,-099 |
| Policy instance | 3 |
| Insurance contract or identification number | 845087-000,-099 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $744 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,284 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $744 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G# 72573 |
| Policy instance | 1 |
| Insurance contract or identification number | G# 72573 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,987 | | 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 $19,915 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,987 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN A. SCOTTI |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7874100 |
| Policy instance | 5 |
| Insurance contract or identification number | E7874100 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $1,286 | | Total amount of fees paid to insurance company | USD $81 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,193 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 1930155 |
| Policy instance | 8 |
| Insurance contract or identification number | 1930155 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | 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 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | FHM913078-0 |
| Policy instance | 7 |
| Insurance contract or identification number | FHM913078-0 | | Number of Individuals Covered | 217 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $2,300 | | 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 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $32,501 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PIT-001,COB |
| Policy instance | 6 |
| Insurance contract or identification number | PIT-001,COB | | Number of Individuals Covered | 190 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $1,813 | | Total amount of fees paid to insurance company | USD $816 | | 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 $18,126 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 843582-000,-099 |
| Policy instance | 4 |
| Insurance contract or identification number | 843582-000,-099 | | Number of Individuals Covered | 263 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $8,724 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $160,608 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 845087-000,-099 |
| Policy instance | 3 |
| Insurance contract or identification number | 845087-000,-099 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $868 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,544 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 215072 |
| Policy instance | 2 |
| Insurance contract or identification number | 215072 | | Number of Individuals Covered | 256 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $4,638 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $69,948 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G# 72573 |
| Policy instance | 1 |
| Insurance contract or identification number | G# 72573 | | Number of Individuals Covered | 65 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $3,181 | | 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 $21,207 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 215072 |
| Policy instance | 4 |
| Insurance contract or identification number | 215072 | | Number of Individuals Covered | 258 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $4,625 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,527 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,625 | | Insurance broker organization code? | 3 | | Insurance broker name | TEAM SCOTTI |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 1930155 |
| Policy instance | 10 |
| Insurance contract or identification number | 1930155 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | 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 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | FHM913078-0 |
| Policy instance | 9 |
| Insurance contract or identification number | FHM913078-0 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $2,621 | | 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 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $37,395 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,621 | | Insurance broker organization code? | 3 | | Insurance broker name | TEAM SCOTTI |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PIT-001,COB |
| Policy instance | 8 |
| Insurance contract or identification number | PIT-001,COB | | Number of Individuals Covered | 185 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $1,861 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,606 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,861 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN SCOTTI |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7874100 |
| Policy instance | 7 |
| Insurance contract or identification number | E7874100 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $1,343 | | Total amount of fees paid to insurance company | USD $100 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,610 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $547 | | Amount paid for insurance broker fees | 66 | | Additional information about fees paid to insurance broker | NON-CASH INCENTIVES | | Insurance broker organization code? | 3 | | Insurance broker name | BRYAN TATE |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 843582-000,-099 |
| Policy instance | 6 |
| Insurance contract or identification number | 843582-000,-099 | | Number of Individuals Covered | 263 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $6,073 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $131,801 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,073 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN SCOTTI |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 845087-000,-099 |
| Policy instance | 5 |
| Insurance contract or identification number | 845087-000,-099 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $1,049 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,689 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,049 | | Insurance broker organization code? | 3 | | Insurance broker name | TEAM SCOTTI |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G# 72573 |
| Policy instance | 3 |
| Insurance contract or identification number | G# 72573 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $3,535 | | 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 $23,570 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,535 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN SCOTTI |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 4935700 4935770 |
| Policy instance | 2 |
| Insurance contract or identification number | 4935700 4935770 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $3,164 | | 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 | | Commission paid to Insurance Broker | USD $3,164 | | Insurance broker organization code? | 3 | | Insurance broker name | TEAM SCOTTI |
|
| KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 ) |
| Policy contract number | 4935700 4935770 |
| Policy instance | 1 |
| Insurance contract or identification number | 4935700 4935770 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $64,080 | | 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 | | Commission paid to Insurance Broker | USD $64,080 | | Insurance broker organization code? | 3 | | Insurance broker name | TEAM SCOTTI |
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