SELIG SEALING PRODUCTS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan SELIG SEALING PRODUCTS, INC. WELFARE PLAN
| 2023: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2023 form 5500 responses |
|---|
| 2023-04-01 | Type of plan entity | Single employer plan |
| 2023-04-01 | Submission has been amended | No |
| 2023-04-01 | This submission is the final filing | Yes |
| 2023-04-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2023-04-01 | Plan is a collectively bargained plan | No |
| 2023-04-01 | Plan funding arrangement – Insurance | Yes |
| 2023-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-04-01 | Type of plan entity | Single employer plan |
| 2022-04-01 | Submission has been amended | No |
| 2022-04-01 | This submission is the final filing | No |
| 2022-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-04-01 | Plan is a collectively bargained plan | No |
| 2022-04-01 | Plan funding arrangement – Insurance | Yes |
| 2022-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-04-01 | Type of plan entity | Single employer plan |
| 2021-04-01 | Submission has been amended | No |
| 2021-04-01 | This submission is the final filing | No |
| 2021-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-04-01 | Plan is a collectively bargained plan | No |
| 2021-04-01 | Plan funding arrangement – Insurance | Yes |
| 2021-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-04-01 | Type of plan entity | Single employer plan |
| 2020-04-01 | Submission has been amended | No |
| 2020-04-01 | This submission is the final filing | No |
| 2020-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-04-01 | Plan is a collectively bargained plan | No |
| 2020-04-01 | Plan funding arrangement – Insurance | Yes |
| 2020-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-04-01 | Type of plan entity | Single employer plan |
| 2019-04-01 | Submission has been amended | No |
| 2019-04-01 | This submission is the final filing | No |
| 2019-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-04-01 | Plan is a collectively bargained plan | No |
| 2019-04-01 | Plan funding arrangement – Insurance | Yes |
| 2019-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-04-01 | Type of plan entity | Single employer plan |
| 2018-04-01 | Plan funding arrangement – Insurance | Yes |
| 2018-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-04-01 | Type of plan entity | Single employer plan |
| 2017-04-01 | Plan funding arrangement – Insurance | Yes |
| 2017-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-04-01 | Type of plan entity | Single employer plan |
| 2016-04-01 | Plan funding arrangement – Insurance | Yes |
| 2016-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-04-01 | Type of plan entity | Single employer plan |
| 2015-04-01 | Plan funding arrangement – Insurance | Yes |
| 2015-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-04-01 | Type of plan entity | Single employer plan |
| 2014-04-01 | Plan funding arrangement – Insurance | Yes |
| 2014-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-04-01 | Type of plan entity | Single employer plan |
| 2013-04-01 | Plan funding arrangement – Insurance | Yes |
| 2013-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-04-01 | Type of plan entity | Single employer plan |
| 2012-04-01 | Plan funding arrangement – Insurance | Yes |
| 2012-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: SELIG SEALING PRODUCTS, INC. WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-04-01 | Type of plan entity | Single employer plan |
| 2011-04-01 | Plan funding arrangement – Insurance | Yes |
| 2011-04-01 | Plan benefit arrangement – Insurance | Yes |
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | VF027307 |
| Policy instance | 4 |
| Insurance contract or identification number | VF027307 | | Number of Individuals Covered | 173 | | Insurance policy start date | 2023-04-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $23,632 | | Total amount of fees paid to insurance company | USD $11,678 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $185,877 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 13177 |
| Policy instance | 3 |
| Insurance contract or identification number | 13177 | | Number of Individuals Covered | 384 | | Insurance policy start date | 2023-04-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $53,095 | | Total amount of fees paid to insurance company | USD $2,124 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,397,896 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 2 |
| Insurance contract or identification number | 755312 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2023-04-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $1,981 | | Total amount of fees paid to insurance company | USD $198 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 1 |
| Insurance contract or identification number | 755312 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2023-04-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $3,373 | | Total amount of fees paid to insurance company | USD $1,315 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | 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 $37,767 | | 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 | VF027307 |
| Policy instance | 5 |
| Insurance contract or identification number | VF027307 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $27,165 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $223,375 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 1 |
| Insurance contract or identification number | 755312 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $2 | | Total amount of fees paid to insurance company | USD $0 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 3 |
| Insurance contract or identification number | 755312 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $2,472 | | Total amount of fees paid to insurance company | USD $307 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 13177 |
| Policy instance | 4 |
| Insurance contract or identification number | 13177 | | Number of Individuals Covered | 395 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $101,961 | | Total amount of fees paid to insurance company | USD $2,040 | | 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 $3,060,672 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 2 |
| Insurance contract or identification number | 755312 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $8,941 | | Total amount of fees paid to insurance company | USD $1,891 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | 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 $54,503 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 2 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 1 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 3 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 4 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 5 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B13177 |
| Policy instance | 6 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 1 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 2 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 3 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 4 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 5 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B13177 |
| Policy instance | 6 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B13177, P43574 |
| Policy instance | 1 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 2 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 3 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 4 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30047643 |
| Policy instance | 5 |
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 11437 |
| Policy instance | 1 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | P43574/P43575/5 |
| Policy instance | 2 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 3 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30047643 |
| Policy instance | 4 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30047643 |
| Policy instance | 4 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 755312 |
| Policy instance | 3 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | P43574/P43575/5 |
| Policy instance | 2 |
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 11437 |
| Policy instance | 1 |
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10541 |
| Policy instance | 1 |
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 235619 |
| Policy instance | 3 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30047643 |
| Policy instance | 4 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | P13177/P43573/4 |
| Policy instance | 2 |
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10541 |
| Policy instance | 1 |
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 235619 |
| Policy instance | 3 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | P13177/P43573/4 |
| Policy instance | 2 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30047643 |
| Policy instance | 4 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 013177 |
| Policy instance | 2 |
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10541 |
| Policy instance | 1 |
| PROTEC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 15297 ) |
| Policy contract number | 10541 |
| Policy instance | 5 |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1026725 |
| Policy instance | 3 |
| TRUASSURE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92525 ) |
| Policy contract number | 10541 |
| Policy instance | 4 |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1026725 |
| Policy instance | 2 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | P13177 |
| Policy instance | 3 |
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10541 |
| Policy instance | 4 |
| TRUASSURE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92525 ) |
| Policy contract number | 10541 |
| Policy instance | 1 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 151591 |
| Policy instance | 3 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 151591 |
| Policy instance | 2 |
| TRUASSURE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92525 ) |
| Policy contract number | 10541 |
| Policy instance | 1 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 151591 |
| Policy instance | 4 |
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10541 |
| Policy instance | 5 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | P13177 |
| Policy instance | 6 |
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10541 |
| Policy instance | 5 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | P13177 |
| Policy instance | 6 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 151591 |
| Policy instance | 1 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 151591 |
| Policy instance | 2 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 151591 |
| Policy instance | 3 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 860717G |
| Policy instance | 4 |
