WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 401k Plan overview

Plan Name	WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN
Plan identification number	502

WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision

401k Sponsoring company profile

WISCONSIN PUBLIC SERVICE CORPORATION (WPSC) has sponsored the creation of one or more 401k plans.

Company Name:	WISCONSIN PUBLIC SERVICE CORPORATION (WPSC)
Employer identification number (EIN):	390715160
NAIC Classification:	221100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2022-01-01
502	2021-01-01
502	2020-01-01
502	2019-01-01
502	2018-01-01
502	2017-01-01	LISA R. GEORGE
502	2016-01-01	LISA R. GEORGE
502	2015-01-01	LISA R. GEORGE
502	2014-01-01	LISA R. GEORGE
502	2013-01-01	LINDA M. KALLAS		WILLIAM J. GUC	2014-10-13
502	2012-01-01	LINDA M. KALLAS		WILLIAM J. GUC	2013-10-11
502	2011-01-01	LINDA M. KALLAS		WILLIAM J. GUC	2012-09-28
502	2010-01-01	DIANE L. FORD		WILLIAM J. GUC	2011-10-04
502	2009-01-01	D.L. FORD - ADMINISTRATOR COMMITTEE		B.A. JOHNSON - TREASURER	2010-10-03

Plan Statistics for WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN

401k plan membership statisitcs for WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN

Measure	Date	Value
2022: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	657
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	0
Number of retired or separated participants receiving benefits	2022-01-01	685
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	685
2021: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	655
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	0
Number of retired or separated participants receiving benefits	2021-01-01	657
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	657
2020: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	611
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	0
Number of retired or separated participants receiving benefits	2020-01-01	655
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	655
2019: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	686
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	611
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	611
2018: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	676
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	0
Number of retired or separated participants receiving benefits	2018-01-01	686
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	686
2017: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,768
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,098
Number of retired or separated participants receiving benefits	2017-01-01	676
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	1,774
2016: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,986
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,103
Number of retired or separated participants receiving benefits	2016-01-01	665
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	1,768
2015: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	2,124
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,343
Number of retired or separated participants receiving benefits	2015-01-01	643
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	1,986
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
2014: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	2,442
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,502
Number of retired or separated participants receiving benefits	2014-01-01	605
Number of other retired or separated participants entitled to future benefits	2014-01-01	17
Total of all active and inactive participants	2014-01-01	2,124
2013: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	2,324
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,731
Number of retired or separated participants receiving benefits	2013-01-01	697
Number of other retired or separated participants entitled to future benefits	2013-01-01	14
Total of all active and inactive participants	2013-01-01	2,442
2012: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	2,229
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,607
Number of retired or separated participants receiving benefits	2012-01-01	700
Number of other retired or separated participants entitled to future benefits	2012-01-01	17
Total of all active and inactive participants	2012-01-01	2,324
2011: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	2,302
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,511
Number of retired or separated participants receiving benefits	2011-01-01	698
Number of other retired or separated participants entitled to future benefits	2011-01-01	20
Total of all active and inactive participants	2011-01-01	2,229
2010: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	2,515
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	1,522
Number of retired or separated participants receiving benefits	2010-01-01	586
Number of other retired or separated participants entitled to future benefits	2010-01-01	194
Total of all active and inactive participants	2010-01-01	2,302
2009: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	2,430
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	1,721
Number of retired or separated participants receiving benefits	2009-01-01	609
Number of other retired or separated participants entitled to future benefits	2009-01-01	185
Total of all active and inactive participants	2009-01-01	2,515

Financial Data on WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN

Measure	Date	Value
2022 : WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$1,730,261
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$1,723,007
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$1,668,944
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$1,730,261
Value of total assets at end of year	2022-12-31	$117,957
Value of total assets at beginning of year	2022-12-31	$110,703
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$54,063
Total interest from all sources	2022-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$25,000,000
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$1,418,196
Participant contributions at end of year	2022-12-31	$117,957
Participant contributions at beginning of year	2022-12-31	$110,703
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$7,254
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$117,957
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$110,703
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Expenses. Payments to insurance carriers foe the provision of benefits	2022-12-31	$404,958
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$312,065
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$1,263,986
Contract administrator fees	2022-12-31	$54,063
Did the plan have assets held for investment	2022-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2022-12-31	410746749
2021 : WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$2,494,927
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$2,507,826
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$2,440,180
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$2,494,927
Value of total assets at end of year	2021-12-31	$110,703
Value of total assets at beginning of year	2021-12-31	$123,602
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$67,646
Total interest from all sources	2021-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$25,000,000
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$1,474,979
Participant contributions at end of year	2021-12-31	$110,703
Participant contributions at beginning of year	2021-12-31	$123,602
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$-12,899
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$110,703
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$123,602
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Expenses. Payments to insurance carriers foe the provision of benefits	2021-12-31	$498,554
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$1,019,948
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$1,941,626
Contract administrator fees	2021-12-31	$67,646
Did the plan have assets held for investment	2021-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2021-12-31	410746749
2018 : WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$1,599,822
Total income from all sources (including contributions)	2018-12-31	$1,459,388
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$-178,948
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$-211,572
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$1,459,388
Value of total assets at end of year	2018-12-31	$135,967
Value of total assets at beginning of year	2018-12-31	$97,453
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$32,624
Total interest from all sources	2018-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$25,000,000
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$1,459,388
Participant contributions at end of year	2018-12-31	$135,967
Participant contributions at beginning of year	2018-12-31	$97,433
Liabilities. Value of operating payables at end of year	2018-12-31	$0
Liabilities. Value of operating payables at beginning of year	2018-12-31	$152
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$1,638,336
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$135,967
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$-1,502,369
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$20
Expenses. Payments to insurance carriers foe the provision of benefits	2018-12-31	$525,087
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$-736,659
Contract administrator fees	2018-12-31	$32,624
Liabilities. Value of benefit claims payable at end of year	2018-12-31	$0
Liabilities. Value of benefit claims payable at beginning of year	2018-12-31	$1,599,670
Did the plan have assets held for investment	2018-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2018-12-31	410746749
2017 : WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$1,599,822
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$1,712,634
Total income from all sources (including contributions)	2017-12-31	$17,216,681
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$17,904,103
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$16,960,639
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$17,209,745
Value of total assets at end of year	2017-12-31	$97,453
Value of total assets at beginning of year	2017-12-31	$897,687
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$943,464
Total interest from all sources	2017-12-31	$-235
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$2,665
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2017-12-31	$2,665
Administrative expenses professional fees incurred	2017-12-31	$9,037
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$25,000,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$4,418,137
Participant contributions at end of year	2017-12-31	$97,433
Participant contributions at beginning of year	2017-12-31	$272,960
Value of other receiveables (less allowance for doubtful accounts) at end of year	2017-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2017-12-31	$3,155
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2017-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2017-12-31	$1,055
Other income not declared elsewhere	2017-12-31	$1,362
Administrative expenses (other) incurred	2017-12-31	$2,074
Liabilities. Value of operating payables at end of year	2017-12-31	$152
Liabilities. Value of operating payables at beginning of year	2017-12-31	$2,846
Total non interest bearing cash at end of year	2017-12-31	$0
Total non interest bearing cash at beginning of year	2017-12-31	$128,479
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$-687,422
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$-1,502,369
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$-814,947
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2017-12-31	$20
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-12-31	$493,093
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2017-12-31	$-235
Expenses. Payments to insurance carriers foe the provision of benefits	2017-12-31	$2,019,205
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-12-31	$3,144
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Contributions received in cash from employer	2017-12-31	$12,791,608
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$14,941,434
Contract administrator fees	2017-12-31	$932,353
Liabilities. Value of benefit claims payable at end of year	2017-12-31	$1,599,670
Liabilities. Value of benefit claims payable at beginning of year	2017-12-31	$1,708,733
Did the plan have assets held for investment	2017-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2017-12-31	410746749
2016 : WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$1,712,634
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$1,727,629
Total income from all sources (including contributions)	2016-12-31	$15,148,342
Total loss/gain on sale of assets	2016-12-31	$0
Total of all expenses incurred	2016-12-31	$17,204,962
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$16,272,564
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$15,136,849
Value of total assets at end of year	2016-12-31	$897,687
Value of total assets at beginning of year	2016-12-31	$2,969,302
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$932,398
Total interest from all sources	2016-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Administrative expenses professional fees incurred	2016-12-31	$10,790
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$15,000,000
If this is an individual account plan, was there a blackout period	2016-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$4,985,326
Participant contributions at end of year	2016-12-31	$272,960
Participant contributions at beginning of year	2016-12-31	$161,014
Value of other receiveables (less allowance for doubtful accounts) at end of year	2016-12-31	$3,155
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2016-12-31	$2,980
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2016-12-31	$1,055
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2016-12-31	$2,320
Liabilities. Value of operating payables at end of year	2016-12-31	$2,846
Liabilities. Value of operating payables at beginning of year	2016-12-31	$18,988
Total non interest bearing cash at end of year	2016-12-31	$128,479
Total non interest bearing cash at beginning of year	2016-12-31	$1,445,633
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Value of net income/loss	2016-12-31	$-2,056,620
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$-814,947
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$1,241,673
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2016-12-31	$493,093
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2016-12-31	$1,359,675
Expenses. Payments to insurance carriers foe the provision of benefits	2016-12-31	$2,049,005
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2016-12-31	$11,493
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2016-12-31	No
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Contributions received in cash from employer	2016-12-31	$10,151,523
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$14,223,559
Contract administrator fees	2016-12-31	$921,608
Liabilities. Value of benefit claims payable at end of year	2016-12-31	$1,708,733
Liabilities. Value of benefit claims payable at beginning of year	2016-12-31	$1,706,321
Did the plan have assets held for investment	2016-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2016-12-31	Disclaimer
Accountancy firm name	2016-12-31	CLIFTONLARSONALLEN
Accountancy firm EIN	2016-12-31	410746749
2015 : WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$1,727,629
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$2,846,792
Total income from all sources (including contributions)	2015-12-31	$20,339,944
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$18,555,557
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$17,131,023
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$20,311,286
Value of total assets at end of year	2015-12-31	$2,969,302
Value of total assets at beginning of year	2015-12-31	$2,304,078
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$1,424,534
Total interest from all sources	2015-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Administrative expenses professional fees incurred	2015-12-31	$43,815
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$15,000,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$4,922,593
Participant contributions at end of year	2015-12-31	$161,014
Participant contributions at beginning of year	2015-12-31	$100,914
Assets. Other investments not covered elsewhere at beginning of year	2015-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2015-12-31	$0
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2015-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2015-12-31	$2,980
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2015-12-31	$184,076
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2015-12-31	$2,320
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2015-12-31	$1,774
Administrative expenses (other) incurred	2015-12-31	$124,290
Liabilities. Value of operating payables at end of year	2015-12-31	$18,988
Liabilities. Value of operating payables at beginning of year	2015-12-31	$43,527
Total non interest bearing cash at end of year	2015-12-31	$1,445,633
Total non interest bearing cash at beginning of year	2015-12-31	$821,919
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Income. Non cash contributions	2015-12-31	$0
Value of net income/loss	2015-12-31	$1,784,387
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$1,241,673
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$-542,714
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Investment advisory and management fees	2015-12-31	$140
Value of interest in registered invesment companies (eg mutual funds) at end of year	2015-12-31	$1,359,675
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$1,197,169
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2015-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2015-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2015-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2015-12-31	$2,021,831
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$28,658
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2015-12-31	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$15,388,693
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$15,109,192
Asset. Corporate debt instrument debt (other) at end of year	2015-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2015-12-31	$0
Contract administrator fees	2015-12-31	$1,256,289
Assets. Corporate common stocks other than exployer securities at end of year	2015-12-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2015-12-31	$0
Liabilities. Value of benefit claims payable at end of year	2015-12-31	$1,706,321
Liabilities. Value of benefit claims payable at beginning of year	2015-12-31	$2,801,491
Did the plan have assets held for investment	2015-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	SCHENCK, SC
Accountancy firm EIN	2015-12-31	391173131
2014 : WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2014 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2014-12-31	$36,008
Total unrealized appreciation/depreciation of assets	2014-12-31	$36,008
Total transfer of assets from this plan	2014-12-31	$232,343
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$2,846,792
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$2,606,526
Total income from all sources (including contributions)	2014-12-31	$22,683,213
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$23,409,999
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$21,471,077
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$22,615,460
Value of total assets at end of year	2014-12-31	$2,304,078
Value of total assets at beginning of year	2014-12-31	$3,022,941
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$1,938,922
Total interest from all sources	2014-12-31	$31,745
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Administrative expenses professional fees incurred	2014-12-31	$43,682
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$15,000,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$6,996,488
Participant contributions at end of year	2014-12-31	$100,914
Participant contributions at beginning of year	2014-12-31	$106,355
Assets. Other investments not covered elsewhere at end of year	2014-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2014-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2014-12-31	$184,076
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2014-12-31	$191,946
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2014-12-31	$1,774
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2014-12-31	$0
Administrative expenses (other) incurred	2014-12-31	$6,790
Liabilities. Value of operating payables at end of year	2014-12-31	$43,527
Liabilities. Value of operating payables at beginning of year	2014-12-31	$50,441
Total non interest bearing cash at end of year	2014-12-31	$821,919
Total non interest bearing cash at beginning of year	2014-12-31	$1,624,318
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$-726,786
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$-542,714
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$416,415
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Investment advisory and management fees	2014-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2014-12-31	$1,197,169
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2014-12-31	$1,100,322
Income. Interest from corporate debt instruments	2014-12-31	$31,745
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2014-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2014-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2014-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2014-12-31	$680,560
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$15,618,972
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$20,790,517
Asset. Corporate debt instrument debt (other) at end of year	2014-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2014-12-31	$0
Contract administrator fees	2014-12-31	$1,888,450
Assets. Corporate common stocks other than exployer securities at end of year	2014-12-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2014-12-31	$0
Liabilities. Value of benefit claims payable at end of year	2014-12-31	$2,801,491
Liabilities. Value of benefit claims payable at beginning of year	2014-12-31	$2,556,085
Did the plan have assets held for investment	2014-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	SCHENCK, SC
Accountancy firm EIN	2014-12-31	391173131
2013 : WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2013 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2013-12-31	$-55,112
Total unrealized appreciation/depreciation of assets	2013-12-31	$-55,112
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$2,606,526
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$3,002,207
Total income from all sources (including contributions)	2013-12-31	$23,215,179
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$23,128,523
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$21,470,608
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$23,234,884
Value of total assets at end of year	2013-12-31	$3,022,941
Value of total assets at beginning of year	2013-12-31	$3,331,966
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$1,657,915
Total interest from all sources	2013-12-31	$35,186
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$124
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-12-31	No
Administrative expenses professional fees incurred	2013-12-31	$47,978
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$15,000,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$6,196,400
Participant contributions at end of year	2013-12-31	$106,355
Participant contributions at beginning of year	2013-12-31	$103,818
Assets. Other investments not covered elsewhere at end of year	2013-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2013-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2013-12-31	$191,946
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2013-12-31	$184,531
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2013-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2013-12-31	$7,243
Other income not declared elsewhere	2013-12-31	$97
Administrative expenses (other) incurred	2013-12-31	$-9,826
Liabilities. Value of operating payables at end of year	2013-12-31	$50,441
Liabilities. Value of operating payables at beginning of year	2013-12-31	$101,171
Total non interest bearing cash at end of year	2013-12-31	$1,624,318
Total non interest bearing cash at beginning of year	2013-12-31	$1,609,701
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$86,656
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$416,415
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$329,759
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Investment advisory and management fees	2013-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2013-12-31	$1,100,322
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2013-12-31	$1,433,916
Income. Interest from corporate debt instruments	2013-12-31	$35,186
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2013-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2013-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2013-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2013-12-31	$631,863
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Contributions received in cash from employer	2013-12-31	$17,038,484
Income. Dividends from common stock	2013-12-31	$124
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$20,838,745
Asset. Corporate debt instrument debt (other) at end of year	2013-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2013-12-31	$0
Contract administrator fees	2013-12-31	$1,619,763
Assets. Corporate common stocks other than exployer securities at end of year	2013-12-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2013-12-31	$0
Liabilities. Value of benefit claims payable at end of year	2013-12-31	$2,556,085
Liabilities. Value of benefit claims payable at beginning of year	2013-12-31	$2,893,793
Did the plan have assets held for investment	2013-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2013-12-31	Disclaimer
Accountancy firm name	2013-12-31	SCHENCK, SC
Accountancy firm EIN	2013-12-31	391173131
2012 : WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2012 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2012-12-31	$223,825
Total unrealized appreciation/depreciation of assets	2012-12-31	$223,825
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$3,002,207
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$3,826,781
Total income from all sources (including contributions)	2012-12-31	$22,784,429
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$24,690,009
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$23,141,467
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$22,497,006
Value of total assets at end of year	2012-12-31	$3,331,966
Value of total assets at beginning of year	2012-12-31	$6,062,120
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$1,548,542
Total interest from all sources	2012-12-31	$38,348
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$19,222
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Administrative expenses professional fees incurred	2012-12-31	$95,150
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$15,000,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$5,734,568
Participant contributions at end of year	2012-12-31	$103,818
Participant contributions at beginning of year	2012-12-31	$101,511
Assets. Other investments not covered elsewhere at end of year	2012-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2012-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2012-12-31	$184,531
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2012-12-31	$5,377
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2012-12-31	$7,243
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2012-12-31	$112,746
Other income not declared elsewhere	2012-12-31	$6,028
Administrative expenses (other) incurred	2012-12-31	$36,268
Liabilities. Value of operating payables at end of year	2012-12-31	$101,171
Liabilities. Value of operating payables at beginning of year	2012-12-31	$83,288
Total non interest bearing cash at end of year	2012-12-31	$1,609,701
Total non interest bearing cash at beginning of year	2012-12-31	$1,606,641
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$-1,905,580
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$329,759
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$2,235,339
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2012-12-31	$1,433,916
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-12-31	$4,348,591
Income. Interest from corporate debt instruments	2012-12-31	$38,348
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2012-12-31	$1,153,691
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$16,762,438
Income. Dividends from common stock	2012-12-31	$19,222
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$21,987,776
Asset. Corporate debt instrument debt (other) at end of year	2012-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2012-12-31	$0
Contract administrator fees	2012-12-31	$1,417,124
Assets. Corporate common stocks other than exployer securities at end of year	2012-12-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2012-12-31	$0
Liabilities. Value of benefit claims payable at end of year	2012-12-31	$2,893,793
Liabilities. Value of benefit claims payable at beginning of year	2012-12-31	$3,630,747
Did the plan have assets held for investment	2012-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	SCHENCK SC
Accountancy firm EIN	2012-12-31	391173131
2011 : WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2011 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2011-12-31	$195,889
Total unrealized appreciation/depreciation of assets	2011-12-31	$195,889
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$3,826,781
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$4,259,073
Total income from all sources (including contributions)	2011-12-31	$21,374,818
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$24,808,846
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$23,427,870
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$21,130,224
Value of total assets at end of year	2011-12-31	$6,062,120
Value of total assets at beginning of year	2011-12-31	$9,928,440
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$1,380,976
Total interest from all sources	2011-12-31	$99,606
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$51,205
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Administrative expenses professional fees incurred	2011-12-31	$86,999
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$15,000,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$6,113,244
Participant contributions at end of year	2011-12-31	$101,511
Participant contributions at beginning of year	2011-12-31	$147,650
Assets. Other investments not covered elsewhere at end of year	2011-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2011-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2011-12-31	$5,377
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2011-12-31	$221,984
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2011-12-31	$112,746
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2011-12-31	$172,669
Other income not declared elsewhere	2011-12-31	$-102,106
Liabilities. Value of operating payables at end of year	2011-12-31	$83,288
Liabilities. Value of operating payables at beginning of year	2011-12-31	$96,482
Total non interest bearing cash at end of year	2011-12-31	$1,606,641
Total non interest bearing cash at beginning of year	2011-12-31	$1,976,454
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$-3,434,028
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$2,235,339
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$5,669,367
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2011-12-31	$4,348,591
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2011-12-31	$7,582,352
Income. Interest from corporate debt instruments	2011-12-31	$99,606
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2011-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2011-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2011-12-31	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2011-12-31	$619,350
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	Yes
Was there a failure to transmit to the plan any participant contributions	2011-12-31	No
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Contributions received in cash from employer	2011-12-31	$15,016,980
Income. Dividends from common stock	2011-12-31	$51,205
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$22,808,520
Asset. Corporate debt instrument debt (other) at end of year	2011-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2011-12-31	$0
Contract administrator fees	2011-12-31	$1,293,977
Assets. Corporate common stocks other than exployer securities at end of year	2011-12-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2011-12-31	$0
Liabilities. Value of benefit claims payable at end of year	2011-12-31	$3,630,747
Liabilities. Value of benefit claims payable at beginning of year	2011-12-31	$3,989,922
Did the plan have assets held for investment	2011-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	SCHENCK SC
Accountancy firm EIN	2011-12-31	391173131
2010 : WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2010 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2010-12-31	$401,845
Total unrealized appreciation/depreciation of assets	2010-12-31	$401,845
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$4,259,073
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$4,452,006
Total income from all sources (including contributions)	2010-12-31	$24,592,012
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$27,220,738
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$25,784,723
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$23,875,743
Value of total assets at end of year	2010-12-31	$9,928,440
Value of total assets at beginning of year	2010-12-31	$12,750,099
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$1,436,015
Total interest from all sources	2010-12-31	$120,002
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$82,610
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Administrative expenses professional fees incurred	2010-12-31	$79,200
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$5,865,942
Participant contributions at end of year	2010-12-31	$147,650
Participant contributions at beginning of year	2010-12-31	$150,110
Assets. Other investments not covered elsewhere at end of year	2010-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2010-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2010-12-31	$212,230
Value of other receiveables (less allowance for doubtful accounts) at end of year	2010-12-31	$221,984
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2010-12-31	$155,322
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2010-12-31	$172,669
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2010-12-31	$333,534
Other income not declared elsewhere	2010-12-31	$111,812
Administrative expenses (other) incurred	2010-12-31	$0
Liabilities. Value of operating payables at end of year	2010-12-31	$96,482
Liabilities. Value of operating payables at beginning of year	2010-12-31	$88,349
Total non interest bearing cash at end of year	2010-12-31	$1,976,454
Total non interest bearing cash at beginning of year	2010-12-31	$2,032,532
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$-2,628,726
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$5,669,367
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$8,298,093
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Investment advisory and management fees	2010-12-31	$31,750
Value of interest in registered invesment companies (eg mutual funds) at end of year	2010-12-31	$7,582,352
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2010-12-31	$3,464,082
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2010-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2010-12-31	$487,211
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2010-12-31	$487,211
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2010-12-31	$120,002
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2010-12-31	$541,590
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$17,797,571
Income. Dividends from common stock	2010-12-31	$82,610
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$25,243,133
Asset. Corporate debt instrument debt (other) at end of year	2010-12-31	$0
Asset. Corporate debt instrument debt (other) at beginning of year	2010-12-31	$2,259,858
Contract administrator fees	2010-12-31	$1,325,065
Assets. Corporate common stocks other than exployer securities at end of year	2010-12-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2010-12-31	$4,200,984
Liabilities. Value of benefit claims payable at end of year	2010-12-31	$3,989,922
Liabilities. Value of benefit claims payable at beginning of year	2010-12-31	$4,030,123
Did the plan have assets held for investment	2010-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	DELOITTE & TOUCHE
Accountancy firm EIN	2010-12-31	133891517

Form 5500 Responses for WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN

2022: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Mulitple employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Mulitple employer plan
2012-01-01	Submission has been amended	Yes
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Mulitple employer plan
2011-01-01	Submission has been amended	No
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 funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Mulitple employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: WISCONSIN PUBLIC SERVICE CORPORATION ADMINISTRATIVE EMPLOYEES' HEALTH CARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Mulitple 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 funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	1007104
Policy instance	3
Insurance contract or identification number 1007104 Number of Individuals Covered 225 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $1,422 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $24,591 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,422 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	1007103
Policy instance	2
Insurance contract or identification number 1007103 Number of Individuals Covered 317 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $843 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,585 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $843 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
SIERRA HEALTH & LIFE (National Association of Insurance Commissioners NAIC id number: 71420 )
Policy contract number	H2001
Policy instance	1
Insurance contract or identification number H2001 Number of Individuals Covered 815 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $658,389 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9713207
Policy instance	1
Insurance contract or identification number 9713207 Number of Individuals Covered 301 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,052 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,822 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,052 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
SIERRA HEALTH & LIFE (National Association of Insurance Commissioners NAIC id number: 71420 )
Policy contract number	H2001
Policy instance	3
Insurance contract or identification number H2001 Number of Individuals Covered 798 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $653,565 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9798729
Policy instance	2
Insurance contract or identification number 9798729 Number of Individuals Covered 214 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,801 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,940 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,801 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	1007103
Policy instance	4
Insurance contract or identification number 1007103 Number of Individuals Covered 0 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,193 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	1007104
Policy instance	5
Insurance contract or identification number 1007104 Number of Individuals Covered 0 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $94 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,951 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $94 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713207
Policy instance	1
Insurance contract or identification number 9713207 Number of Individuals Covered 296 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $958 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,661 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $958 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9798729
Policy instance	2
Insurance contract or identification number 9798729 Number of Individuals Covered 214 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,629 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $25,823 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,629 Insurance broker organization code? 3
SIERRA HEALTH & LIFE (National Association of Insurance Commissioners NAIC id number: 71420 )
Policy contract number	H2001
Policy instance	3
Insurance contract or identification number H2001 Number of Individuals Covered 775 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $925,654 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SIERRA HEALTH & LIFE (National Association of Insurance Commissioners NAIC id number: 71420 )
Policy contract number	H2001
Policy instance	3
Insurance contract or identification number H2001 Number of Individuals Covered 636 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $671,042 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713207
Policy instance	1
Insurance contract or identification number 9713207 Number of Individuals Covered 231 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $451 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,683 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $237 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9798729
Policy instance	2
Insurance contract or identification number 9798729 Number of Individuals Covered 192 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $796 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,395 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $409 Insurance broker organization code? 3
SIERRA HEALTH & LIFE (National Association of Insurance Commissioners NAIC id number: 71420 )
Policy contract number	H2001
Policy instance	3
Insurance contract or identification number H2001 Number of Individuals Covered 642 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,513,049 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9798729
Policy instance	2
Insurance contract or identification number 9798729 Number of Individuals Covered 192 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $1,675 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,063 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,675 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713207
Policy instance	1
Insurance contract or identification number 9713207 Number of Individuals Covered 250 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $982 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,540 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $982 Insurance broker organization code? 3
CARE-PLUS DENTAL PLANS INC. (National Association of Insurance Commissioners NAIC id number: 55328 )
Policy contract number	PPD 370
Policy instance	6
Insurance contract or identification number PPD 370 Number of Individuals Covered 26 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $25,432 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SIERRA HEALTH & LIFE (National Association of Insurance Commissioners NAIC id number: 71420 )
Policy contract number	H2001
Policy instance	5
Insurance contract or identification number H2001 Number of Individuals Covered 616 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,806,214 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9798737
Policy instance	4
Insurance contract or identification number 9798737 Number of Individuals Covered 10 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $133 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,277 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $133 Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES - BOR
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713207
Policy instance	1
Insurance contract or identification number 9713207 Number of Individuals Covered 1238 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $4,683 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $55,292 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,683 Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES - BOR
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713223
Policy instance	2
Insurance contract or identification number 9713223 Number of Individuals Covered 27 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $128 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,367 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $128 Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES - BOR
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9798729
Policy instance	3
Insurance contract or identification number 9798729 Number of Individuals Covered 1078 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $9,807 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $112,647 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,807 Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES - BOR
COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 )
Policy contract number	248962
Policy instance	7
Insurance contract or identification number 248962 Number of Individuals Covered 15 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,632 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED HEALTHCARE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 52411 )
Policy contract number	24270/71/72
Policy instance	5
Insurance contract or identification number 24270/71/72 Number of Individuals Covered 654 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 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 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 $1,923,913 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9798737
Policy instance	4
Insurance contract or identification number 9798737 Number of Individuals Covered 8 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of fees paid to insurance company USD $42 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $599 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 42 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
COMBINED INSURANCE OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62148 )
Policy contract number	9798729
Policy instance	3
Insurance contract or identification number 9798729 Number of Individuals Covered 1455 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of fees paid to insurance company USD $12,391 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $156,327 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 12391 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713223
Policy instance	2
Insurance contract or identification number 9713223 Number of Individuals Covered 11 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of fees paid to insurance company USD $36 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $451 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 36 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713207
Policy instance	1
Insurance contract or identification number 9713207 Number of Individuals Covered 1856 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $7,200 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $89,549 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 7200 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713223
Policy instance	1
Insurance contract or identification number 9713223 Number of Individuals Covered 13 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 $45 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $614 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 45 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713207
Policy instance	2
Insurance contract or identification number 9713207 Number of Individuals Covered 2032 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 $7,317 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $99,013 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 7317 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
COMBINED INSURANCE OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62148 )
Policy contract number	9798729
Policy instance	3
Insurance contract or identification number 9798729 Number of Individuals Covered 1455 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 $11,446 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $155,359 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 11446 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
HEALTH ALLIANCE MEDICAL PLANS (National Association of Insurance Commissioners NAIC id number: 77950 )
Policy contract number	02339A
Policy instance	5
Insurance contract or identification number 02339A Number of Individuals Covered 3 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 $1,678 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 $55,286 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1678 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9798737
Policy instance	4
Insurance contract or identification number 9798737 Number of Individuals Covered 3 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 $24 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $333 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 24 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713207
Policy instance	2
Insurance contract or identification number 9713207 Number of Individuals Covered 2514 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 $8,840 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $110,506 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 8840 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713223
Policy instance	1
Insurance contract or identification number 9713223 Number of Individuals Covered 13 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 $40 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $498 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 40 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
COMBINED INSURANCE OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62148 )
Policy contract number	9798729
Policy instance	3
Insurance contract or identification number 9798729 Number of Individuals Covered 614 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 $4,727 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $59,087 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 4727 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9798737
Policy instance	4
Insurance contract or identification number 9798737 Number of Individuals Covered 1 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 $6 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $73 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 6 Additional information about fees paid to insurance broker PREMIUM COMMISSION Insurance broker organization code? 3 Insurance broker name VERITAS RISK SERVICES, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9733601
Policy instance	2
Insurance contract or identification number 9733601 Number of Individuals Covered 9 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $897 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713207
Policy instance	3
Insurance contract or identification number 9713207 Number of Individuals Covered 2692 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $120,263 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMBINED INSURANCE OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62148 )
Policy contract number	9798729
Policy instance	4
Insurance contract or identification number 9798729 Number of Individuals Covered 1143 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $114,422
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9798737
Policy instance	5
Insurance contract or identification number 9798737 Number of Individuals Covered 1 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $169
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713223
Policy instance	1
Insurance contract or identification number 9713223 Number of Individuals Covered 2 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $67 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713207
Policy instance	3
Insurance contract or identification number 9713207 Number of Individuals Covered 3047 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $137,293 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713223
Policy instance	1
Insurance contract or identification number 9713223 Number of Individuals Covered 8 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,013 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9733601
Policy instance	2
Insurance contract or identification number 9733601 Number of Individuals Covered 106 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,271 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMBINED INSURANCE OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62148 )
Policy contract number	9798729
Policy instance	4
Insurance contract or identification number 9798729 Number of Individuals Covered 630 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $61,577
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9733601
Policy instance	2
Insurance contract or identification number 9733601 Number of Individuals Covered 309 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $33,070 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713207
Policy instance	3
Insurance contract or identification number 9713207 Number of Individuals Covered 2973 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $135,624 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COMBINED INSURANCE OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62148 )
Policy contract number	9733619
Policy instance	4
Insurance contract or identification number 9733619 Number of Individuals Covered 1 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $111 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9713223
Policy instance	1
Insurance contract or identification number 9713223 Number of Individuals Covered 119 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 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 Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,265 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No

Potentially related plans

• WISCONSIN PUBLIC SERVICE CORPORATION LIFE AND LONG TERM DISABILITY PLAN [EIN = 391075160]