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ACTON MEDICAL ASSOCIATES, P. C. HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan NameACTON MEDICAL ASSOCIATES, P. C. HEALTH AND WELFARE BENEFIT PLAN
Plan identification number 501

ACTON MEDICAL ASSOCIATES, P. C. HEALTH AND WELFARE BENEFIT PLAN Benefits

401k Plan Type
Plan Features/Benefits

    401k Sponsoring company profile

    ACTON MEDICAL ASSOCIATES, P. C. has sponsored the creation of one or more 401k plans.

    Company Name:ACTON MEDICAL ASSOCIATES, P. C.
    Employer identification number (EIN):043038356
    NAIC Classification:621111
    NAIC Description:Offices of Physicians (except Mental Health Specialists)

    Form 5500 Filing Information

    Submission information for form 5500 for 401k plan ACTON MEDICAL ASSOCIATES, P. C. HEALTH AND WELFARE BENEFIT PLAN

    Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
    5012019-01-01
    5012018-01-01DEBORAH B. KOVACS, M.D.
    5012017-01-01DEBORAH KOVACS
    5012016-01-01CHRISTOPHER COOPER
    5012015-01-01CHRISTOPHER COOPER CHRISTOPHER COOPER2016-07-20
    5012014-01-01CHRISTOPHER COOPER CHRISTOPHER COOPER2015-07-10
    5012013-01-01CHRISTOPHER COOPER CHRISTOPHER COOPER2014-07-11
    5012012-01-01DEBORAH KOVACS DEBORAH KOVACS2013-07-12
    5012011-01-01DEBORAH KOVACS
    5012010-01-01DEBORAH KOVACS DEBORAH KOVACS2013-07-12
    5012009-01-01DEBORAH B. KOVALS, MD

    Plan Statistics for ACTON MEDICAL ASSOCIATES, P. C. HEALTH AND WELFARE BENEFIT PLAN

    401k plan membership statisitcs for ACTON MEDICAL ASSOCIATES, P. C. HEALTH AND WELFARE BENEFIT PLAN

    Measure Date Value
    2019
    Total participants, beginning-of-year2019-01-01173
    Total number of active participants reported on line 7a of the Form 55002019-01-01167
    Number of retired or separated participants receiving benefits2019-01-012
    Number of other retired or separated participants entitled to future benefits2019-01-010
    Total of all active and inactive participants2019-01-01169
    2018
    Total participants, beginning-of-year2018-01-01173
    Total number of active participants reported on line 7a of the Form 55002018-01-01172
    Number of retired or separated participants receiving benefits2018-01-011
    Number of other retired or separated participants entitled to future benefits2018-01-010
    Total of all active and inactive participants2018-01-01173
    2017
    Total participants, beginning-of-year2017-01-01167
    Total number of active participants reported on line 7a of the Form 55002017-01-01171
    Number of retired or separated participants receiving benefits2017-01-012
    Number of other retired or separated participants entitled to future benefits2017-01-010
    Total of all active and inactive participants2017-01-01173
    2016
    Total participants, beginning-of-year2016-01-01168
    Total number of active participants reported on line 7a of the Form 55002016-01-01167
    Number of retired or separated participants receiving benefits2016-01-010
    Number of other retired or separated participants entitled to future benefits2016-01-010
    Total of all active and inactive participants2016-01-01167
    2015
    Total participants, beginning-of-year2015-01-01168
    Total number of active participants reported on line 7a of the Form 55002015-01-01166
    Number of retired or separated participants receiving benefits2015-01-012
    Number of other retired or separated participants entitled to future benefits2015-01-010
    Total of all active and inactive participants2015-01-01168
    2014
    Total participants, beginning-of-year2014-01-01161
    Total number of active participants reported on line 7a of the Form 55002014-01-01167
    Number of retired or separated participants receiving benefits2014-01-012
    Total of all active and inactive participants2014-01-01169
    2013
    Total participants, beginning-of-year2013-01-01168
    Total number of active participants reported on line 7a of the Form 55002013-01-01160
    Number of retired or separated participants receiving benefits2013-01-011
    Total of all active and inactive participants2013-01-01161
    2012
    Total participants, beginning-of-year2012-01-01204
    Total number of active participants reported on line 7a of the Form 55002012-01-01163
    Number of retired or separated participants receiving benefits2012-01-015
    Total of all active and inactive participants2012-01-01168
    2011
    Total participants, beginning-of-year2011-01-01204
    Total number of active participants reported on line 7a of the Form 55002011-01-01201
    Number of retired or separated participants receiving benefits2011-01-013
    Number of other retired or separated participants entitled to future benefits2011-01-010
    Total of all active and inactive participants2011-01-01204
    2010
    Total participants, beginning-of-year2010-01-01173
    Total number of active participants reported on line 7a of the Form 55002010-01-01201
    Number of retired or separated participants receiving benefits2010-01-013
    Number of other retired or separated participants entitled to future benefits2010-01-010
    Total of all active and inactive participants2010-01-01204
    2009
    Total participants, beginning-of-year2009-01-01160
    Total number of active participants reported on line 7a of the Form 55002009-01-01173
    Total of all active and inactive participants2009-01-01173

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

    Insurance Providers Used on plan

    EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
    Policy contract number10048341001
    Policy instance 6
    Insurance contract or identification number10048341001
    Number of Individuals Covered106
    Insurance policy start date2019-01-01
    Insurance policy end date2019-12-31
    Total amount of commissions paid to insurance brokerUSD $692
    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 BenefitYes
    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 $6,943
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $692
    Insurance broker organization code?3
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number162539
    Policy instance 5
    Insurance contract or identification number162539
    Number of Individuals Covered114
    Insurance policy start date2019-01-01
    Insurance policy end date2019-12-31
    Total amount of commissions paid to insurance brokerUSD $9,553
    Total amount of fees paid to insurance companyUSD $1,040
    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 BenefitYes
    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 $9,553
    Amount paid for insurance broker fees1040
    Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
    Insurance broker organization code?3
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number971028134617
    Policy instance 4
    Insurance contract or identification number971028134617
    Number of Individuals Covered170
    Insurance policy start date2019-01-01
    Insurance policy end date2019-12-31
    Total amount of commissions paid to insurance brokerUSD $29,899
    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 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 $996,614
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $29,899
    Insurance broker organization code?3
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number162539
    Policy instance 3
    Insurance contract or identification number162539
    Number of Individuals Covered165
    Insurance policy start date2019-01-01
    Insurance policy end date2019-12-31
    Total amount of commissions paid to insurance brokerUSD $12,029
    Total amount of fees paid to insurance companyUSD $1,252
    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 BenefitYes
    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 $12,029
    Amount paid for insurance broker fees1252
    Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
    Insurance broker organization code?3
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number4958291
    Policy instance 2
    Insurance contract or identification number4958291
    Number of Individuals Covered227
    Insurance policy start date2019-01-01
    Insurance policy end date2019-12-31
    Total amount of commissions paid to insurance brokerUSD $6,508
    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 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
    Welfare Benefit Premiums Paid to CarrierUSD $109,016
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $6,508
    Insurance broker organization code?3
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number162539
    Policy instance 1
    Insurance contract or identification number162539
    Number of Individuals Covered167
    Insurance policy start date2019-01-01
    Insurance policy end date2019-12-31
    Total amount of commissions paid to insurance brokerUSD $2,840
    Total amount of fees paid to insurance companyUSD $298
    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 BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    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
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $2,840
    Amount paid for insurance broker fees298
    Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
    Insurance broker organization code?3
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number162539
    Policy instance 5
    Insurance contract or identification number162539
    Number of Individuals Covered120
    Insurance policy start date2018-01-01
    Insurance policy end date2018-12-31
    Total amount of commissions paid to insurance brokerUSD $6,466
    Total amount of fees paid to insurance companyUSD $1,055
    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 BenefitYes
    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 $6,466
    Amount paid for insurance broker fees1055
    Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
    Insurance broker organization code?3
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number162539
    Policy instance 1
    Insurance contract or identification number162539
    Number of Individuals Covered165
    Insurance policy start date2018-01-01
    Insurance policy end date2018-12-31
    Total amount of commissions paid to insurance brokerUSD $1,841
    Total amount of fees paid to insurance companyUSD $290
    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 BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    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
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,841
    Amount paid for insurance broker fees290
    Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
    Insurance broker organization code?3
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number4958291
    Policy instance 2
    Insurance contract or identification number4958291
    Number of Individuals Covered245
    Insurance policy start date2018-01-01
    Insurance policy end date2018-12-31
    Total amount of commissions paid to insurance brokerUSD $6,778
    Total amount of fees paid to insurance companyUSD $1,935
    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 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 $112,951
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $6,778
    Amount paid for insurance broker fees1935
    Additional information about fees paid to insurance brokerOTHER RETENTION CHARGES
    Insurance broker organization code?3
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number162539
    Policy instance 3
    Insurance contract or identification number162539
    Number of Individuals Covered162
    Insurance policy start date2018-01-01
    Insurance policy end date2018-12-31
    Total amount of commissions paid to insurance brokerUSD $7,800
    Total amount of fees paid to insurance companyUSD $1,231
    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 BenefitYes
    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 $7,800
    Amount paid for insurance broker fees1231
    Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
    Insurance broker organization code?3
    EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
    Policy contract number10048341001
    Policy instance 6
    Insurance contract or identification number10048341001
    Number of Individuals Covered107
    Insurance policy start date2018-01-01
    Insurance policy end date2018-12-31
    Total amount of commissions paid to insurance brokerUSD $713
    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 BenefitYes
    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 $7,142
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $713
    Insurance broker organization code?3
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number971028134617
    Policy instance 4
    Insurance contract or identification number971028134617
    Number of Individuals Covered172
    Insurance policy start date2018-01-01
    Insurance policy end date2018-12-31
    Total amount of commissions paid to insurance brokerUSD $24,810
    Total amount of fees paid to insurance companyUSD $5,549
    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 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 $1,001,951
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $24,810
    Amount paid for insurance broker fees5549
    Additional information about fees paid to insurance brokerOTHER
    Insurance broker organization code?3
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number162539
    Policy instance 1
    Insurance contract or identification number162539
    Number of Individuals Covered170
    Insurance policy start date2017-01-01
    Insurance policy end date2017-12-31
    Total amount of commissions paid to insurance brokerUSD $1,994
    Total amount of fees paid to insurance companyUSD $508
    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 BenefitYes
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    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
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,994
    Amount paid for insurance broker fees508
    Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP INC.
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number162539
    Policy instance 5
    Insurance contract or identification number162539
    Number of Individuals Covered125
    Insurance policy start date2017-01-01
    Insurance policy end date2017-12-31
    Total amount of commissions paid to insurance brokerUSD $7,204
    Total amount of fees paid to insurance companyUSD $1,847
    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 BenefitYes
    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 $7,204
    Amount paid for insurance broker fees1847
    Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP INC.
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number971028134617
    Policy instance 4
    Insurance contract or identification number971028134617
    Number of Individuals Covered171
    Insurance policy start date2017-01-01
    Insurance policy end date2017-12-31
    Total amount of commissions paid to insurance brokerUSD $22,351
    Total amount of fees paid to insurance companyUSD $215
    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 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 $853,715
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $22,351
    Amount paid for insurance broker fees215
    Additional information about fees paid to insurance brokerOTHER
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP INC.
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number162539
    Policy instance 3
    Insurance contract or identification number162539
    Number of Individuals Covered168
    Insurance policy start date2017-01-01
    Insurance policy end date2017-12-31
    Total amount of commissions paid to insurance brokerUSD $8,559
    Total amount of fees paid to insurance companyUSD $2,155
    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 BenefitYes
    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 $8,559
    Amount paid for insurance broker fees2155
    Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP INC.
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number4958291
    Policy instance 2
    Insurance contract or identification number4958291
    Number of Individuals Covered272
    Insurance policy start date2017-01-01
    Insurance policy end date2017-12-31
    Total amount of commissions paid to insurance brokerUSD $7,040
    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 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 $7,040
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP INC.
    EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
    Policy contract number10048341001
    Policy instance 6
    Insurance contract or identification number10048341001
    Number of Individuals Covered104
    Insurance policy start date2017-01-01
    Insurance policy end date2017-12-31
    Total amount of commissions paid to insurance brokerUSD $696
    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 BenefitYes
    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 $7,556
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $696
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract numberSOK603092
    Policy instance 6
    Insurance contract or identification numberSOK603092
    Number of Individuals Covered166
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $334
    Total amount of fees paid to insurance companyUSD $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 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
    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 $2,228
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $334
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
    Policy contract number013167
    Policy instance 5
    Insurance contract or identification number013167
    Number of Individuals Covered317
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $5,916
    Total amount of fees paid to insurance companyUSD $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 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
    Welfare Benefit Premiums Paid to CarrierUSD $118,764
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $5,916
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract numberSGD604646
    Policy instance 4
    Insurance contract or identification numberSGD604646
    Number of Individuals Covered165
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $11,550
    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 BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitYes
    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 $77,003
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $11,550
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract numberSGM604616
    Policy instance 3
    Insurance contract or identification numberSGM604616
    Number of Individuals Covered166
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $2,268
    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 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 $15,117
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $2,268
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract numberVDT601054
    Policy instance 2
    Insurance contract or identification numberVDT601054
    Number of Individuals Covered120
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $9,651
    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 BenefitNo
    Temporary Disability Insurance Welfare BenefitYes
    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 $64,338
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $9,651
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number971028134617
    Policy instance 1
    Insurance contract or identification number971028134617
    Number of Individuals Covered220
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $26,176
    Total amount of fees paid to insurance companyUSD $8,008
    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 $1,112,915
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $26,176
    Amount paid for insurance broker fees8008
    Additional information about fees paid to insurance brokerFEES
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract numberSGM604616
    Policy instance 1
    Insurance contract or identification numberSGM604616
    Number of Individuals Covered167
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $1,567
    Total amount of fees paid to insurance companyUSD $717
    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 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 $10,449
    Commission paid to Insurance BrokerUSD $1,567
    Amount paid for insurance broker fees717
    Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
    Policy contract number0131670000
    Policy instance 2
    Insurance contract or identification number0131670000
    Number of Individuals Covered300
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $4,109
    Total amount of fees paid to insurance companyUSD $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 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
    Welfare Benefit Premiums Paid to CarrierUSD $108,051
    Commission paid to Insurance BrokerUSD $4,109
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract numberSGD604646
    Policy instance 3
    Insurance contract or identification numberSGD604646
    Number of Individuals Covered165
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $8,080
    Total amount of fees paid to insurance companyUSD $3,727
    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 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 BenefitYes
    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 $53,867
    Commission paid to Insurance BrokerUSD $8,080
    Amount paid for insurance broker fees3727
    Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number971028134617
    Policy instance 4
    Insurance contract or identification number971028134617
    Number of Individuals Covered210
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $31,559
    Total amount of fees paid to insurance companyUSD $56
    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 $1,175,756
    Commission paid to Insurance BrokerUSD $31,559
    Amount paid for insurance broker fees56
    Additional information about fees paid to insurance brokerFEES
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract numberVDT601054
    Policy instance 6
    Insurance contract or identification numberVDT601054
    Number of Individuals Covered130
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $7,788
    Total amount of fees paid to insurance companyUSD $3,266
    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 BenefitNo
    Temporary Disability Insurance Welfare BenefitYes
    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 $51,920
    Commission paid to Insurance BrokerUSD $7,788
    Amount paid for insurance broker fees3266
    Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
    Policy contract numberSOK603092
    Policy instance 5
    Insurance contract or identification numberSOK603092
    Number of Individuals Covered167
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $231
    Total amount of fees paid to insurance companyUSD $106
    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 BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedACCIDENTAL DEATH
    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 $1,540
    Commission paid to Insurance BrokerUSD $231
    Amount paid for insurance broker fees106
    Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number152499
    Policy instance 1
    Insurance contract or identification number152499
    Number of Individuals Covered160
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $19,276
    Total amount of fees paid to insurance companyUSD $1,286
    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 BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    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
    Commission paid to Insurance BrokerUSD $19,276
    Amount paid for insurance broker fees1286
    Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION PAID
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number62916065
    Policy instance 3
    Insurance contract or identification number62916065
    Number of Individuals Covered2
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    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?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 $11,518
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number4956343
    Policy instance 2
    Insurance contract or identification number4956343
    Number of Individuals Covered312
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $41,267
    Total amount of fees paid to insurance companyUSD $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 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 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
    Welfare Benefit Premiums Paid to CarrierUSD $1,335,962
    Commission paid to Insurance BrokerUSD $41,267
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number152499
    Policy instance 1
    Insurance contract or identification number152499
    Number of Individuals Covered163
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $17,687
    Total amount of fees paid to insurance companyUSD $2,467
    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 BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    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
    Commission paid to Insurance BrokerUSD $17,687
    Amount paid for insurance broker fees2467
    Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION PAID
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number62916065
    Policy instance 5
    Insurance contract or identification number62916065
    Number of Individuals Covered2
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    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?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 $10,128
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number62916000
    Policy instance 4
    Insurance contract or identification number62916000
    Number of Individuals Covered77
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $21,045
    Total amount of fees paid to insurance companyUSD $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 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 $815,085
    Commission paid to Insurance BrokerUSD $21,045
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number4956343
    Policy instance 2
    Insurance contract or identification number4956343
    Number of Individuals Covered308
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $4,676
    Total amount of fees paid to insurance companyUSD $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 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
    Welfare Benefit Premiums Paid to CarrierUSD $111,456
    Commission paid to Insurance BrokerUSD $4,676
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number67116000
    Policy instance 3
    Insurance contract or identification number67116000
    Number of Individuals Covered20
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $6,209
    Total amount of fees paid to insurance companyUSD $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 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 $264,372
    Commission paid to Insurance BrokerUSD $6,209
    Insurance broker organization code?3
    Insurance broker nameTHE HAYS GROUP, INC.
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number62916000
    Policy instance 1
    Insurance contract or identification number62916000
    Number of Individuals Covered84
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $25,655
    Total amount of fees paid to insurance companyUSD $5,213
    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 $871,924
    STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
    Policy contract number152499
    Policy instance 2
    Insurance contract or identification number152499
    Number of Individuals Covered164
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $20,622
    Total amount of fees paid to insurance companyUSD $4,551
    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 BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    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
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number67116000
    Policy instance 3
    Insurance contract or identification number67116000
    Number of Individuals Covered14
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $5,750
    Total amount of fees paid to insurance companyUSD $485
    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 $196,211
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number62916065
    Policy instance 4
    Insurance contract or identification number62916065
    Number of Individuals Covered2
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    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?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 $12,480
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number4956343
    Policy instance 5
    Insurance contract or identification number4956343
    Number of Individuals Covered295
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $4,648
    Total amount of fees paid to insurance companyUSD $29
    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
    Welfare Benefit Premiums Paid to CarrierUSD $110,593
    BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
    Policy contract number4956343
    Policy instance 1
    Insurance contract or identification number4956343
    Number of Individuals Covered143
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $4,749
    Total amount of fees paid to insurance companyUSD $242
    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
    Welfare Benefit Premiums Paid to CarrierUSD $112,261
    MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
    Policy contract numberG000ACSD
    Policy instance 2
    Insurance contract or identification numberG000ACSD
    Number of Individuals Covered176
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $13,957
    Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
    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 $148,733
    FALLON COMMUNITY HEALTH PLAN -MEDICARE (National Association of Insurance Commissioners NAIC id number: 95541 )
    Policy contract number4452471
    Policy instance 3
    Insurance contract or identification number4452471
    Number of Individuals Covered84
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $9,297
    Total amount of fees paid to insurance companyUSD $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 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 $441,332
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number67116000
    Policy instance 4
    Insurance contract or identification number67116000
    Number of Individuals Covered4
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $1,842
    Total amount of fees paid to insurance companyUSD $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 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 $55,264
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number62916000
    Policy instance 6
    Insurance contract or identification number62916000
    Number of Individuals Covered59
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $23,597
    Total amount of fees paid to insurance companyUSD $7,648
    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 $620,792
    TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
    Policy contract number62916065
    Policy instance 5
    Insurance contract or identification number62916065
    Number of Individuals Covered3
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $400
    Total amount of fees paid to insurance companyUSD $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 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 $11,814

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