401k Plan data: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN plan

UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 401k Plan overview

Plan Name	UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN
Plan identification number	501

UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

UNIVERSITY SUBURBAN HEALTH CENTER has sponsored the creation of one or more 401k plans.

Company Name: UNIVERSITY SUBURBAN HEALTH CENTER

Employer identification number (EIN): 341125708

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Additional information about UNIVERSITY SUBURBAN HEALTH CENTER

Jurisdiction of Incorporation: Ohio Secretary of State Business Services Division

Incorporation Date: 1973-01-26

Company Identification Number: 434823

Legal Registered Office Address: 1611 SOUTH GREEN RD #A61
-
SOUTH EUCLID
United States of America (USA)
44121

More information about UNIVERSITY SUBURBAN HEALTH CENTER

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2014-01-01 DOUGLAS ECKERT
501 2013-01-01 DOUGLAS ECKERT
501 2012-01-01 CHARLES R ABBEY
501 2011-01-01 CHARLES ABBEY
501 2009-01-01 CHARLES ABBEY

Plan id#	Filing Submission Date	Name of Administrator
501	2014-01-01	DOUGLAS ECKERT
501	2013-01-01	DOUGLAS ECKERT
501	2012-01-01	CHARLES R ABBEY
501	2011-01-01	CHARLES ABBEY
501	2009-01-01	CHARLES ABBEY

Plan Statistics for UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN

401k plan membership statisitcs for UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN

Measure Date Value
2014: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 75
Number of retired or separated participants receiving benefits 2014-01-01 3
Total of all active and inactive participants 2014-01-01 78
2013: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 100
Total of all active and inactive participants 2013-01-01 100
2012: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 109
Total of all active and inactive participants 2012-01-01 109
2011: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 109
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 109
2009: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 126
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 126

Measure	Date	Value
2014: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	75
Number of retired or separated participants receiving benefits	2014-01-01	3
Total of all active and inactive participants	2014-01-01	78
2013: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	100
Total of all active and inactive participants	2013-01-01	100
2012: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	109
Total of all active and inactive participants	2012-01-01	109
2011: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	109
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	109
2009: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	126
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	126

Form 5500 Responses for UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN

2014: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	Yes
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: UNIVERSITY SUBURBAN HEALTH CENTER MEDICAL BENEFITS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 177211

Policy instance

Insurance contract or identification number	VG 177211
Number of Individuals Covered	12
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $513
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 $5,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $513
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL131753

Policy instance

Insurance contract or identification number	GL131753
Number of Individuals Covered	98
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $328
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 $3,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $328
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD106850

Policy instance

Insurance contract or identification number	LTD106850
Number of Individuals Covered	88
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $1,087
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 $7,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,087
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G153875

Policy instance

Insurance contract or identification number	G153875
Number of Individuals Covered	13
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $791
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 $5,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $791
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD107219

Policy instance

Insurance contract or identification number	LTD107219
Number of Individuals Covered	12
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $762
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 $5,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $762
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, LLC

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

523

Policy instance

Insurance contract or identification number	523
Number of Individuals Covered	60
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,025
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,025
Insurance broker organization code?	3
Insurance broker name	BRITTON GALLAGHER & ASSOCIATES, INC

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

649411

Policy instance

Insurance contract or identification number	649411
Number of Individuals Covered	55
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $27,492
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 $685,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,429
Insurance broker organization code?	3
Insurance broker name	BRITTON GALLAGHER & ASSOCIATES, INC

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00171164

Policy instance

Insurance contract or identification number	00171164
Number of Individuals Covered	73
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $37,023
Total amount of fees paid to insurance company	USD $394
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 $803,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,023
Amount paid for insurance broker fees	394
Additional information about fees paid to insurance broker	BONUS, OVERRIDE, AND NON-MONETARYCOMPENSATION
Insurance broker organization code?	3
Insurance broker name	BRITTON GALLAGHER & ASSOCIATES, INC

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05997356

Policy instance

Insurance contract or identification number	TM05997356
Number of Individuals Covered	83
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $203
Total amount of fees paid to insurance company	USD $27
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 $47,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $203
Amount paid for insurance broker fees	27
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	BRITTON GALLAGHER & ASSOCIATES, INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD107219

Policy instance

Insurance contract or identification number	LTD107219
Number of Individuals Covered	12
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $861
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 177211

Policy instance

Insurance contract or identification number	VG 177211
Number of Individuals Covered	13
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $612
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 $6,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $612
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G153875

Policy instance

Insurance contract or identification number	G153875
Number of Individuals Covered	13
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $888
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 $5,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $888
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD106850

Policy instance

Insurance contract or identification number	LTD106850
Number of Individuals Covered	88
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $1,311
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 $8,742
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,311
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL131753

Policy instance

Insurance contract or identification number	GL131753
Number of Individuals Covered	100
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $361
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 $3,291
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $361
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL131753

Policy instance

Insurance contract or identification number	GL131753
Number of Individuals Covered	109
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $369
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 $3,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $369
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 177211

Policy instance

Insurance contract or identification number	VG 177211
Number of Individuals Covered	13
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G153875

Policy instance

Insurance contract or identification number	G153875
Number of Individuals Covered	15
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD106850

Policy instance

Insurance contract or identification number	LTD106850
Number of Individuals Covered	109
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $1,383
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 $9,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,383
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, INC.

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00171164

Policy instance

Insurance contract or identification number	00171164
Number of Individuals Covered	81
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $42,032
Total amount of fees paid to insurance company	USD $3,350
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 $861,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,032
Amount paid for insurance broker fees	3350
Additional information about fees paid to insurance broker	BONUS, OVERRIDE AND NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BRITTON GALLAGHER & ASSOCIATES, INC

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

560495

Policy instance

Insurance contract or identification number	560495
Number of Individuals Covered	83
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,302
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 $66,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,302
Insurance broker organization code?	3
Insurance broker name	BRITTON GALLAGHER & ASSOCIATES, INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD106850

Policy instance

Insurance contract or identification number	LTD106850
Number of Individuals Covered	109
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $1,383
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G153875

Policy instance

Insurance contract or identification number	G153875
Number of Individuals Covered	15
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Are there contracts with allocated funds for individual policies?	No
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 $6,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 177211

Policy instance

Insurance contract or identification number	VG 177211
Number of Individuals Covered	13
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Are there contracts with allocated funds for individual policies?	No
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
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 $5,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00171164

Policy instance

Insurance contract or identification number	00171164
Number of Individuals Covered	158
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $45,121
Total amount of fees paid to insurance company	USD $1,518
Are there contracts with allocated funds for individual policies?	No
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 $1,122,370
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 131753

Policy instance

Insurance contract or identification number	GL 131753
Number of Individuals Covered	109
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $369
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	A,D & D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,428
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

TM05757370

Policy instance

Insurance contract or identification number	TM05757370
Number of Individuals Covered	93
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,685
Total amount of fees paid to insurance company	USD $17
Are there contracts with allocated funds for individual policies?	No
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 $63,090
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

TM05757370

Policy instance

Insurance contract or identification number	TM05757370
Number of Individuals Covered	272
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,887
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 $63,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,887
Insurance broker organization code?	3
Insurance broker name	BRITTON GALLAGHER & ASSOCIATES

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 96518 )

Policy contract number

US415262

Policy instance

Insurance contract or identification number	US415262
Number of Individuals Covered	213
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $42,371
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,153,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,371
Insurance broker organization code?	3
Insurance broker name	BRITTON-GALLAGHER & ASSOCIATES, INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G153875

Policy instance

Insurance contract or identification number	G153875
Number of Individuals Covered	17
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Are there contracts with allocated funds for individual policies?	No
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 $7,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD106850

Policy instance

Insurance contract or identification number	LTD106850
Number of Individuals Covered	117
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $1,508
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,508
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 131753

Policy instance

Insurance contract or identification number	GL 131753
Number of Individuals Covered	117
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $396
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	A,D & D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $396
Insurance broker organization code?	3
Insurance broker name	BGS ASSOCIATES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 177211

Policy instance

Insurance contract or identification number	VG 177211
Number of Individuals Covered	13
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Are there contracts with allocated funds for individual policies?	No
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
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 $4,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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Company Name:	UNIVERSITY SUBURBAN HEALTH CENTER
Employer identification number (EIN):	341125708
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)

Jurisdiction of Incorporation:	Ohio Secretary of State Business Services Division
Incorporation Date:	1973-01-26
Company Identification Number:	434823
Legal Registered Office Address:	1611 SOUTH GREEN RD #A61 - SOUTH EUCLID United States of America (USA) 44121