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FIDELITY HOUSE, INC. FLEXIBLE BENEFITS PLAN 401k Plan overview

Plan NameFIDELITY HOUSE, INC. FLEXIBLE BENEFITS PLAN
Plan identification number 501

FIDELITY HOUSE, INC. FLEXIBLE BENEFITS PLAN Benefits

401k Plan Type
Plan Features/Benefits

    401k Sponsoring company profile

    FIDELITY HOUSE, INC. has sponsored the creation of one or more 401k plans.

    Company Name:FIDELITY HOUSE, INC.
    Employer identification number (EIN):042499679
    NAIC Classification:624310
    NAIC Description:Vocational Rehabilitation Services

    Additional information about FIDELITY HOUSE, INC.

    Jurisdiction of Incorporation: Florida Department of State Division of Corporations
    Incorporation Date: 1984-08-30
    Company Identification Number: N04923
    Legal Registered Office Address: 138-301 KINGS BLVD

    SUN CITY CTR

    33573

    More information about FIDELITY HOUSE, INC.

    Form 5500 Filing Information

    Submission information for form 5500 for 401k plan FIDELITY HOUSE, INC. FLEXIBLE BENEFITS PLAN

    Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
    5012019-01-01
    5012018-01-01RICHARD WILSON
    5012017-11-01ERNEST SIMMONS
    5012016-11-01ERNEST SIMMONS ERNEST SIMMONS2018-07-27
    5012015-11-01GLEN MATTERA
    5012014-11-01YVONNE ALLARD
    5012013-11-01YVONNE ALLARD
    5012012-11-01YVONNE ALLARD
    5012011-11-01YVONNE ALLARD
    5012010-11-01YVONNE ALLARD
    5012009-11-01YVONNE ALLARD

    Plan Statistics for FIDELITY HOUSE, INC. FLEXIBLE BENEFITS PLAN

    401k plan membership statisitcs for FIDELITY HOUSE, INC. FLEXIBLE BENEFITS PLAN

    Measure Date Value
    2019
    Total participants, beginning-of-year2019-01-01216
    Total number of active participants reported on line 7a of the Form 55002019-01-01306
    Total of all active and inactive participants2019-01-01306
    Total participants2019-01-01306
    2018
    Total participants, beginning-of-year2018-01-01205
    Total number of active participants reported on line 7a of the Form 55002018-01-01216
    Total of all active and inactive participants2018-01-01216
    Total participants2018-01-01216
    2017
    Total participants, beginning-of-year2017-11-01205
    Total number of active participants reported on line 7a of the Form 55002017-11-01225
    Total of all active and inactive participants2017-11-01225
    Total participants2017-11-01225
    2016
    Total participants, beginning-of-year2016-11-01205
    Total number of active participants reported on line 7a of the Form 55002016-11-01205
    Total of all active and inactive participants2016-11-01205
    Total participants2016-11-01205
    2015
    Total participants, beginning-of-year2015-11-01205
    Total number of active participants reported on line 7a of the Form 55002015-11-01205
    Total of all active and inactive participants2015-11-01205
    Total participants2015-11-01205
    2014
    Total participants, beginning-of-year2014-11-01227
    Total number of active participants reported on line 7a of the Form 55002014-11-01205
    Total of all active and inactive participants2014-11-01205
    Total participants2014-11-01205
    2013
    Total participants, beginning-of-year2013-11-01216
    Total number of active participants reported on line 7a of the Form 55002013-11-01227
    Total of all active and inactive participants2013-11-01227
    Total participants2013-11-01227
    2012
    Total participants, beginning-of-year2012-11-01217
    Total number of active participants reported on line 7a of the Form 55002012-11-01216
    Total of all active and inactive participants2012-11-01216
    Total participants2012-11-01216
    2011
    Total participants, beginning-of-year2011-11-01216
    Total number of active participants reported on line 7a of the Form 55002011-11-01217
    Total of all active and inactive participants2011-11-01217
    Total participants2011-11-01217
    2010
    Total participants, beginning-of-year2010-11-01194
    Total number of active participants reported on line 7a of the Form 55002010-11-01216
    Total of all active and inactive participants2010-11-01216
    Total participants2010-11-01216
    2009
    Total participants, beginning-of-year2009-11-01184
    Total number of active participants reported on line 7a of the Form 55002009-11-01194
    Total of all active and inactive participants2009-11-01194
    Total participants2009-11-01194

    Form 5500 Responses

    2019
    2019-01-01Type of plan entitySingle employer plan
    2019-01-01Submission has been amendedNo
    2019-01-01This submission is the final filingNo
    2019-01-01This return/report is a short plan year return/report (less than 12 months)No
    2019-01-01Plan is a collectively bargained planNo
    2019-01-01Plan funding arrangement – InsuranceYes
    2019-01-01Plan funding arrangement – General assets of the sponsorYes
    2019-01-01Plan benefit arrangement – InsuranceYes
    2019-01-01Plan benefit arrangement – General assets of the sponsorYes
    2018
    2018-01-01Type of plan entitySingle employer plan
    2018-01-01Submission has been amendedNo
    2018-01-01This submission is the final filingNo
    2018-01-01This return/report is a short plan year return/report (less than 12 months)No
    2018-01-01Plan is a collectively bargained planNo
    2018-01-01Plan funding arrangement – InsuranceYes
    2018-01-01Plan funding arrangement – General assets of the sponsorYes
    2018-01-01Plan benefit arrangement – InsuranceYes
    2018-01-01Plan benefit arrangement – General assets of the sponsorYes
    2017
    2017-11-01Type of plan entitySingle employer plan
    2017-11-01Submission has been amendedNo
    2017-11-01This submission is the final filingNo
    2017-11-01This return/report is a short plan year return/report (less than 12 months)Yes
    2017-11-01Plan is a collectively bargained planNo
    2017-11-01Plan funding arrangement – InsuranceYes
    2017-11-01Plan funding arrangement – General assets of the sponsorYes
    2017-11-01Plan benefit arrangement – InsuranceYes
    2017-11-01Plan benefit arrangement – General assets of the sponsorYes
    2016
    2016-11-01Type of plan entitySingle employer plan
    2016-11-01Submission has been amendedNo
    2016-11-01This submission is the final filingNo
    2016-11-01This return/report is a short plan year return/report (less than 12 months)No
    2016-11-01Plan is a collectively bargained planNo
    2016-11-01Plan funding arrangement – InsuranceYes
    2016-11-01Plan benefit arrangement – InsuranceYes
    2015
    2015-11-01Type of plan entitySingle employer plan
    2015-11-01Submission has been amendedNo
    2015-11-01This submission is the final filingNo
    2015-11-01This return/report is a short plan year return/report (less than 12 months)No
    2015-11-01Plan is a collectively bargained planNo
    2015-11-01Plan funding arrangement – InsuranceYes
    2015-11-01Plan funding arrangement – General assets of the sponsorYes
    2015-11-01Plan benefit arrangement – InsuranceYes
    2015-11-01Plan benefit arrangement – General assets of the sponsorYes
    2014
    2014-11-01Type of plan entitySingle employer plan
    2014-11-01Submission has been amendedNo
    2014-11-01This submission is the final filingNo
    2014-11-01This return/report is a short plan year return/report (less than 12 months)No
    2014-11-01Plan is a collectively bargained planNo
    2014-11-01Plan funding arrangement – InsuranceYes
    2014-11-01Plan funding arrangement – General assets of the sponsorYes
    2014-11-01Plan benefit arrangement – InsuranceYes
    2014-11-01Plan benefit arrangement – General assets of the sponsorYes
    2013
    2013-11-01Type of plan entitySingle employer plan
    2013-11-01Submission has been amendedNo
    2013-11-01This submission is the final filingNo
    2013-11-01This return/report is a short plan year return/report (less than 12 months)No
    2013-11-01Plan is a collectively bargained planNo
    2013-11-01Plan funding arrangement – InsuranceYes
    2013-11-01Plan funding arrangement – General assets of the sponsorYes
    2013-11-01Plan benefit arrangement – InsuranceYes
    2013-11-01Plan benefit arrangement – General assets of the sponsorYes
    2012
    2012-11-01Type of plan entitySingle employer plan
    2012-11-01Submission has been amendedNo
    2012-11-01This submission is the final filingNo
    2012-11-01This return/report is a short plan year return/report (less than 12 months)No
    2012-11-01Plan is a collectively bargained planNo
    2012-11-01Plan funding arrangement – InsuranceYes
    2012-11-01Plan funding arrangement – General assets of the sponsorYes
    2012-11-01Plan benefit arrangement – InsuranceYes
    2012-11-01Plan benefit arrangement – General assets of the sponsorYes
    2011
    2011-11-01Type of plan entitySingle employer plan
    2011-11-01Submission has been amendedNo
    2011-11-01This submission is the final filingNo
    2011-11-01This return/report is a short plan year return/report (less than 12 months)No
    2011-11-01Plan is a collectively bargained planNo
    2011-11-01Plan funding arrangement – InsuranceYes
    2011-11-01Plan funding arrangement – General assets of the sponsorYes
    2011-11-01Plan benefit arrangement – InsuranceYes
    2011-11-01Plan benefit arrangement – General assets of the sponsorYes
    2010
    2010-11-01Type of plan entitySingle employer plan
    2010-11-01Submission has been amendedYes
    2010-11-01This submission is the final filingNo
    2010-11-01This return/report is a short plan year return/report (less than 12 months)No
    2010-11-01Plan is a collectively bargained planNo
    2010-11-01Plan funding arrangement – InsuranceYes
    2010-11-01Plan funding arrangement – General assets of the sponsorYes
    2010-11-01Plan benefit arrangement – InsuranceYes
    2010-11-01Plan benefit arrangement – General assets of the sponsorYes
    2009
    2009-11-01Type of plan entitySingle employer plan
    2009-11-01Submission has been amendedNo
    2009-11-01This submission is the final filingNo
    2009-11-01This return/report is a short plan year return/report (less than 12 months)No
    2009-11-01Plan is a collectively bargained planNo
    2009-11-01Plan funding arrangement – InsuranceYes
    2009-11-01Plan funding arrangement – General assets of the sponsorYes
    2009-11-01Plan benefit arrangement – InsuranceYes
    2009-11-01Plan benefit arrangement – General assets of the sponsorYes

    Insurance Providers Used on plan

    THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
    Policy contract number10234709
    Policy instance 2
    Insurance contract or identification number10234709
    Number of Individuals Covered306
    Insurance policy start date2019-01-01
    Insurance policy end date2019-12-31
    Total amount of commissions paid to insurance brokerUSD $9,269
    Total amount of fees paid to insurance companyUSD $7,738
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&D
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $156,063
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $0
    Amount paid for insurance broker fees4131
    Additional information about fees paid to insurance brokerFEES
    Insurance broker organization code?3
    AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
    Policy contract number19ANO1B338
    Policy instance 1
    Insurance contract or identification number19ANO1B338
    Number of Individuals Covered140
    Insurance policy start date2019-01-01
    Insurance policy end date2019-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $747,512
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Insurance broker organization code?3
    THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
    Policy contract number10234709
    Policy instance 2
    Insurance contract or identification number10234709
    Number of Individuals Covered216
    Insurance policy start date2018-01-01
    Insurance policy end date2018-12-31
    Total amount of commissions paid to insurance brokerUSD $7,332
    Total amount of fees paid to insurance companyUSD $8,682
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&D
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $110,992
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $7,332
    Amount paid for insurance broker fees5703
    Additional information about fees paid to insurance brokerBROKER BONUS
    Insurance broker organization code?3
    AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
    Policy contract number18AN01K264
    Policy instance 1
    Insurance contract or identification number18AN01K264
    Number of Individuals Covered97
    Insurance policy start date2018-01-01
    Insurance policy end date2018-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $430,044
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )
    Policy contract number18AN01K264
    Policy instance 1
    Insurance contract or identification number18AN01K264
    Number of Individuals Covered105
    Insurance policy start date2017-11-01
    Insurance policy end date2017-12-31
    Total amount of commissions paid to insurance brokerUSD $0
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $72,479
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
    Policy contract number10234710
    Policy instance 2
    Insurance contract or identification number10234710
    Number of Individuals Covered225
    Insurance policy start date2017-11-01
    Insurance policy end date2017-12-31
    Total amount of commissions paid to insurance brokerUSD $2,148
    Total amount of fees paid to insurance companyUSD $1,122
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&D
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $18,760
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $0
    Amount paid for insurance broker fees503
    Additional information about fees paid to insurance brokerTPA FEE
    Insurance broker organization code?3
    Insurance broker nameCLARK & LAVEY BENEFITS SOLUTIONS
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number0378778
    Policy instance 4
    Insurance contract or identification number0378778
    Number of Individuals Covered110
    Insurance policy start date2015-11-01
    Insurance policy end date2016-10-31
    Total amount of commissions paid to insurance brokerUSD $3,982
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $3,982
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH, INC.
    AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
    Policy contract number0647925
    Policy instance 3
    Insurance contract or identification number0647925
    Number of Individuals Covered205
    Insurance policy start date2015-11-01
    Insurance policy end date2016-10-31
    Total amount of commissions paid to insurance brokerUSD $3,494
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
    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 CarrierUSD $25,993
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $3,494
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH, INC.
    TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )
    Policy contract number030117065525
    Policy instance 2
    Insurance contract or identification number030117065525
    Number of Individuals Covered18
    Insurance policy start date2015-11-01
    Insurance policy end date2016-10-31
    Total amount of commissions paid to insurance brokerUSD $3,687
    Total amount of fees paid to insurance companyUSD $72
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $163,931
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $3,687
    Amount paid for insurance broker fees72
    Additional information about fees paid to insurance brokerOTHER COMPENSATION PAID
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH, INC.
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number030117065525
    Policy instance 1
    Insurance contract or identification number030117065525
    Number of Individuals Covered158
    Insurance policy start date2015-11-01
    Insurance policy end date2016-10-31
    Total amount of commissions paid to insurance brokerUSD $23,250
    Total amount of fees paid to insurance companyUSD $400
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $1,001,716
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $23,250
    Amount paid for insurance broker fees400
    Additional information about fees paid to insurance brokerOTHER COMPENSATION PAID
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH INC.
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number0378778
    Policy instance 4
    Insurance contract or identification number0378778
    Number of Individuals Covered112
    Insurance policy start date2014-11-01
    Insurance policy end date2015-10-31
    Total amount of commissions paid to insurance brokerUSD $3,993
    Total amount of fees paid to insurance companyUSD $720
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $3,993
    Amount paid for insurance broker fees720
    Additional information about fees paid to insurance brokerOTHER COMMISSION
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH INC.
    AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
    Policy contract number0647925
    Policy instance 3
    Insurance contract or identification number0647925
    Number of Individuals Covered205
    Insurance policy start date2014-11-01
    Insurance policy end date2015-10-31
    Total amount of commissions paid to insurance brokerUSD $3,098
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
    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 CarrierUSD $22,591
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $309
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH
    TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )
    Policy contract number030117065525
    Policy instance 2
    Insurance contract or identification number030117065525
    Number of Individuals Covered19
    Insurance policy start date2014-11-01
    Insurance policy end date2015-10-31
    Total amount of commissions paid to insurance brokerUSD $3,907
    Total amount of fees paid to insurance companyUSD $85
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $182,248
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $3,907
    Amount paid for insurance broker fees85
    Additional information about fees paid to insurance brokerOTHER COMPENSATION PAID
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number030117065525
    Policy instance 1
    Insurance contract or identification number030117065525
    Number of Individuals Covered165
    Insurance policy start date2014-11-01
    Insurance policy end date2015-10-31
    Total amount of commissions paid to insurance brokerUSD $23,006
    Total amount of fees paid to insurance companyUSD $548
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $1,038,518
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $23,006
    Amount paid for insurance broker fees548
    Additional information about fees paid to insurance brokerOTHER COMPENSATON PAID
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number95688
    Policy instance 2
    Insurance contract or identification number95688
    Number of Individuals Covered162
    Insurance policy start date2013-11-01
    Insurance policy end date2014-10-31
    Total amount of commissions paid to insurance brokerUSD $23,859
    Total amount of fees paid to insurance companyUSD $470
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $842,215
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $23,859
    Amount paid for insurance broker fees470
    Additional information about fees paid to insurance brokerOTHER COMPENSATION PAID
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH INC.
    AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
    Policy contract number0647925
    Policy instance 1
    Insurance contract or identification number0647925
    Number of Individuals Covered227
    Insurance policy start date2013-11-01
    Insurance policy end date2014-10-31
    Total amount of commissions paid to insurance brokerUSD $3,229
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    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 CarrierUSD $23,723
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $3,229
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH INC.
    TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )
    Policy contract number45633000
    Policy instance 3
    Insurance contract or identification number45633000
    Number of Individuals Covered17
    Insurance policy start date2013-11-01
    Insurance policy end date2014-10-31
    Total amount of commissions paid to insurance brokerUSD $3,681
    Total amount of fees paid to insurance companyUSD $99
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $126,358
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $3,681
    Amount paid for insurance broker fees99
    Additional information about fees paid to insurance brokerOTHER COMPENSATION PAID
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH INC.
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number0378778
    Policy instance 4
    Insurance contract or identification number0378778
    Number of Individuals Covered114
    Insurance policy start date2013-11-01
    Insurance policy end date2014-10-31
    Total amount of commissions paid to insurance brokerUSD $4,042
    Total amount of fees paid to insurance companyUSD $726
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $4,042
    Amount paid for insurance broker fees726
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH INC.
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number0378778
    Policy instance 3
    Insurance contract or identification number0378778
    Number of Individuals Covered114
    Insurance policy start date2012-11-01
    Insurance policy end date2013-10-31
    Total amount of commissions paid to insurance brokerUSD $4,022
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $4,022
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH INC.
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number50366000
    Policy instance 2
    Insurance contract or identification number50366000
    Number of Individuals Covered88
    Insurance policy start date2012-11-01
    Insurance policy end date2013-10-31
    Total amount of commissions paid to insurance brokerUSD $22,836
    Total amount of fees paid to insurance companyUSD $157
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    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 CarrierUSD $848,361
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $22,836
    Amount paid for insurance broker fees157
    Additional information about fees paid to insurance brokerOTHER BROKER COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH INC.
    AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
    Policy contract number647925
    Policy instance 1
    Insurance contract or identification number647925
    Number of Individuals Covered216
    Insurance policy start date2012-11-01
    Insurance policy end date2013-10-31
    Total amount of commissions paid to insurance brokerUSD $3,102
    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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    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 BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
    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 CarrierUSD $22,856
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $3,102
    Insurance broker organization code?3
    Insurance broker nameFRED C. CHURCH INSURANCE
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number0378778
    Policy instance 3
    Insurance contract or identification number0378778
    Number of Individuals Covered184
    Insurance policy start date2011-11-01
    Insurance policy end date2012-10-31
    Total amount of commissions paid to insurance brokerUSD $3,996
    Total amount of fees paid to insurance companyUSD $504
    Dental Insurance Welfare BenefitYes
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number45633000
    Policy instance 2
    Insurance contract or identification number45633000
    Number of Individuals Covered92
    Insurance policy start date2011-11-01
    Insurance policy end date2012-10-31
    Total amount of commissions paid to insurance brokerUSD $28,411
    Total amount of fees paid to insurance companyUSD $1,224
    Health Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $990,173
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
    Policy contract number647925
    Policy instance 1
    Insurance contract or identification number647925
    Number of Individuals Covered217
    Insurance policy start date2011-11-01
    Insurance policy end date2012-10-31
    Total amount of commissions paid to insurance brokerUSD $3,069
    Life Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
    Welfare Benefit Premiums Paid to CarrierUSD $22,026
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number0378778
    Policy instance 3
    Insurance contract or identification number0378778
    Number of Individuals Covered91
    Insurance policy start date2010-11-01
    Insurance policy end date2011-10-31
    Total amount of commissions paid to insurance brokerUSD $25,034
    Total amount of fees paid to insurance companyUSD $8,199
    Health Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $940,223
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
    Policy contract number647925
    Policy instance 2
    Insurance contract or identification number647925
    Number of Individuals Covered216
    Insurance policy start date2010-11-01
    Insurance policy end date2011-10-31
    Total amount of commissions paid to insurance brokerUSD $2,864
    Life Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
    Welfare Benefit Premiums Paid to CarrierUSD $21,204
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number0378778
    Policy instance 1
    Insurance contract or identification number0378778
    Number of Individuals Covered104
    Insurance policy start date2010-11-01
    Insurance policy end date2011-10-31
    Total amount of commissions paid to insurance brokerUSD $4,020
    Health Insurance Welfare BenefitNo
    Dental Insurance Welfare BenefitYes
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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