401k Plan data: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN plan

NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 401k Plan overview

Plan Name	NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN
Plan identification number	001

NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

NORTHEASTERN WELLNESS SOLUTIONS, INC. has sponsored the creation of one or more 401k plans.

Company Name: NORTHEASTERN WELLNESS SOLUTIONS, INC.

Employer identification number (EIN): 811201914

NAIC Classification: 812190

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01
001 2021-01-01
001 2020-01-01
001 2019-01-01
001 2019-01-01
001 2018-01-01
001 2017-01-01 JODI CLARY
001 2017-01-01
001 2016-01-25 JODI CLARY JODI CLARY 2017-06-12

Plan Statistics for NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN

401k plan membership statisitcs for NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN

Measure Date Value
2022: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 14
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 12
Number of retired or separated participants receiving benefits 2022-01-01 2
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 14
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 14
Number of participants with account balances 2022-01-01 5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 2
2021: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 12
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 10
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 2
Total of all active and inactive participants 2021-01-01 12
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 12
Number of participants with account balances 2021-01-01 7
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 2
2020: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 11
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 11
Total of all active and inactive participants 2020-01-01 11
Total participants 2020-01-01 11
Number of participants with account balances 2020-01-01 5
2019: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 6
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 8
Number of retired or separated participants receiving benefits 2019-01-01 1
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 9
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 9
Number of participants with account balances 2019-01-01 5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2018: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 6
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 5
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 1
Total of all active and inactive participants 2018-01-01 6
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 6
Number of participants with account balances 2018-01-01 3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 1
2017: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 2
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 2
Number of retired or separated participants receiving benefits 2017-01-01 0
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 2
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 2
Number of participants with account balances 2017-01-01 2
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-25 2
Total number of active participants reported on line 7a of the Form 5500 2016-01-25 2
Number of retired or separated participants receiving benefits 2016-01-25 0
Number of other retired or separated participants entitled to future benefits 2016-01-25 0
Total of all active and inactive participants 2016-01-25 2
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-25 0
Total participants 2016-01-25 2
Number of participants with account balances 2016-01-25 2
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-25 0

Measure	Date	Value
2022: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	14
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	12
Number of retired or separated participants receiving benefits	2022-01-01	2
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	14
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	14
Number of participants with account balances	2022-01-01	5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	2
2021: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	12
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	10
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	2
Total of all active and inactive participants	2021-01-01	12
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	12
Number of participants with account balances	2021-01-01	7
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	2
2020: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	11
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	11
Total of all active and inactive participants	2020-01-01	11
Total participants	2020-01-01	11
Number of participants with account balances	2020-01-01	5
2019: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	6
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	8
Number of retired or separated participants receiving benefits	2019-01-01	1
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	9
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	9
Number of participants with account balances	2019-01-01	5
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2018: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	6
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	5
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	1
Total of all active and inactive participants	2018-01-01	6
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	6
Number of participants with account balances	2018-01-01	3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	1
2017: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	2
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	2
Number of retired or separated participants receiving benefits	2017-01-01	0
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	2
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	2
Number of participants with account balances	2017-01-01	2
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-25	2
Total number of active participants reported on line 7a of the Form 5500	2016-01-25	2
Number of retired or separated participants receiving benefits	2016-01-25	0
Number of other retired or separated participants entitled to future benefits	2016-01-25	0
Total of all active and inactive participants	2016-01-25	2
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-25	0
Total participants	2016-01-25	2
Number of participants with account balances	2016-01-25	2
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-25	0

Financial Data on NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN

Measure	Date	Value
2022 : NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2022 401k financial data
Transfers to/from the plan	2022-12-31	$0
Total plan liabilities at end of year	2022-12-31	$0
Total plan liabilities at beginning of year	2022-12-31	$0
Total income from all sources	2022-12-31	$27,082
Expenses. Total of all expenses incurred	2022-12-31	$7,944
Benefits paid (including direct rollovers)	2022-12-31	$7,579
Total plan assets at end of year	2022-12-31	$343,062
Total plan assets at beginning of year	2022-12-31	$323,924
Value of fidelity bond covering the plan	2022-12-31	$10,000
Total contributions received or receivable from participants	2022-12-31	$10,791
Expenses. Other expenses not covered elsewhere	2022-12-31	$0
Contributions received from other sources (not participants or employers)	2022-12-31	$0
Other income received	2022-12-31	$15,291
Noncash contributions received	2022-12-31	$0
Net income (gross income less expenses)	2022-12-31	$19,138
Net plan assets at end of year (total assets less liabilities)	2022-12-31	$343,062
Net plan assets at beginning of year (total assets less liabilities)	2022-12-31	$323,924
Assets. Value of employer securities	2022-12-31	$312,822
Total contributions received or receivable from employer(s)	2022-12-31	$1,000
Value of certain deemed distributions of participant loans	2022-12-31	$0
Value of corrective distributions	2022-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2022-12-31	$365
2021 : NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2021 401k financial data
Total plan liabilities at end of year	2021-12-31	$0
Total plan liabilities at beginning of year	2021-12-31	$0
Total income from all sources	2021-12-31	$100,418
Expenses. Total of all expenses incurred	2021-12-31	$138
Benefits paid (including direct rollovers)	2021-12-31	$0
Total plan assets at end of year	2021-12-31	$323,924
Total plan assets at beginning of year	2021-12-31	$223,644
Value of fidelity bond covering the plan	2021-12-31	$10,000
Total contributions received or receivable from participants	2021-12-31	$9,289
Expenses. Other expenses not covered elsewhere	2021-12-31	$0
Contributions received from other sources (not participants or employers)	2021-12-31	$0
Other income received	2021-12-31	$90,212
Noncash contributions received	2021-12-31	$0
Net income (gross income less expenses)	2021-12-31	$100,280
Net plan assets at end of year (total assets less liabilities)	2021-12-31	$323,924
Net plan assets at beginning of year (total assets less liabilities)	2021-12-31	$223,644
Assets. Value of employer securities	2021-12-31	$291,101
Total contributions received or receivable from employer(s)	2021-12-31	$917
Value of certain deemed distributions of participant loans	2021-12-31	$0
Value of corrective distributions	2021-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2021-12-31	$138
2020 : NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2020 401k financial data
Total income from all sources	2020-12-31	$-75,373
Total plan assets at end of year	2020-12-31	$223,644
Total plan assets at beginning of year	2020-12-31	$299,017
Value of fidelity bond covering the plan	2020-12-31	$10,000
Total contributions received or receivable from participants	2020-12-31	$5,004
Other income received	2020-12-31	$-81,457
Net income (gross income less expenses)	2020-12-31	$-75,373
Net plan assets at end of year (total assets less liabilities)	2020-12-31	$223,644
Net plan assets at beginning of year (total assets less liabilities)	2020-12-31	$299,017
Assets. Value of employer securities	2020-12-31	$204,956
Total contributions received or receivable from employer(s)	2020-12-31	$1,080
2019 : NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2019 401k financial data
Total income from all sources	2019-12-31	$44,175
Expenses. Total of all expenses incurred	2019-12-31	$353
Benefits paid (including direct rollovers)	2019-12-31	$217
Total plan assets at end of year	2019-12-31	$299,017
Total plan assets at beginning of year	2019-12-31	$255,195
Value of fidelity bond covering the plan	2019-12-31	$1,000
Total contributions received or receivable from participants	2019-12-31	$5,057
Other income received	2019-12-31	$38,633
Net income (gross income less expenses)	2019-12-31	$43,822
Net plan assets at end of year (total assets less liabilities)	2019-12-31	$299,017
Net plan assets at beginning of year (total assets less liabilities)	2019-12-31	$255,195
Assets. Value of employer securities	2019-12-31	$251,278
Total contributions received or receivable from employer(s)	2019-12-31	$485
Expenses. Administrative service providers (salaries,fees and commissions)	2019-12-31	$136
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
2018 : NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2018 401k financial data
Transfers to/from the plan	2018-12-31	$0
Total income from all sources	2018-12-31	$67,359
Expenses. Total of all expenses incurred	2018-12-31	$5
Benefits paid (including direct rollovers)	2018-12-31	$0
Total plan assets at end of year	2018-12-31	$255,195
Total plan assets at beginning of year	2018-12-31	$187,841
Total contributions received or receivable from participants	2018-12-31	$498
Expenses. Other expenses not covered elsewhere	2018-12-31	$0
Contributions received from other sources (not participants or employers)	2018-12-31	$3,116
Other income received	2018-12-31	$63,254
Noncash contributions received	2018-12-31	$0
Net income (gross income less expenses)	2018-12-31	$67,354
Net plan assets at end of year (total assets less liabilities)	2018-12-31	$255,195
Net plan assets at beginning of year (total assets less liabilities)	2018-12-31	$187,841
Assets. Value of employer securities	2018-12-31	$251,278
Total contributions received or receivable from employer(s)	2018-12-31	$491
Value of certain deemed distributions of participant loans	2018-12-31	$0
Value of corrective distributions	2018-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2018-12-31	$5
2017 : NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2017 401k financial data
Total income from all sources	2017-12-31	$-203,477
Expenses. Total of all expenses incurred	2017-12-31	$0
Total plan assets at end of year	2017-12-31	$50,240
Total plan assets at beginning of year	2017-12-31	$253,717
Other income received	2017-12-31	$-203,477
Net income (gross income less expenses)	2017-12-31	$-203,477
Net plan assets at end of year (total assets less liabilities)	2017-12-31	$50,240
Net plan assets at beginning of year (total assets less liabilities)	2017-12-31	$253,717
Assets. Value of employer securities	2017-12-31	$50,240
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
2016 : NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2016 401k financial data
Total income from all sources	2016-12-31	$253,719
Expenses. Total of all expenses incurred	2016-12-31	$2
Benefits paid (including direct rollovers)	2016-12-31	$2
Total plan assets at end of year	2016-12-31	$253,717
Contributions received from other sources (not participants or employers)	2016-12-31	$122,484
Other income received	2016-12-31	$131,235
Net income (gross income less expenses)	2016-12-31	$253,717
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$253,717
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$0
Assets. Value of employer securities	2016-12-31	$253,717
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0

Form 5500 Responses for NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN

2022: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	Yes
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 – Trust	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT 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 – Trust	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT 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 – Trust	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: NORTHEASTERN WELLNESS SOLUTIONS RETIREMENT PLAN 2016 form 5500 responses
2016-01-25	Type of plan entity	Single employer plan
2016-01-25	First time form 5500 has been submitted	Yes
2016-01-25	Submission has been amended	No
2016-01-25	This submission is the final filing	No
2016-01-25	This return/report is a short plan year return/report (less than 12 months)	Yes
2016-01-25	Plan is a collectively bargained plan	No
2016-01-25	Plan funding arrangement – Trust	Yes
2016-01-25	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

135571

Policy instance

Insurance contract or identification number	135571
Number of Individuals Covered	3
Total amount of commissions paid to insurance broker	USD $150
Total amount of fees paid to insurance company	USD $16
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	5

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

135571

Policy instance

Insurance contract or identification number	135571
Number of Individuals Covered	5
Total amount of fees paid to insurance company	USD $13
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	13
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker organization code?	5

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

135571

Policy instance

Insurance contract or identification number	135571
Number of Individuals Covered	5
Total amount of fees paid to insurance company	USD $6
Amount paid for insurance broker fees	6
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker organization code?	5

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Company Name:	NORTHEASTERN WELLNESS SOLUTIONS, INC.
Employer identification number (EIN):	811201914
NAIC Classification:	812190