avatar Seton Hall University Services
  • Location: New Jersey 
  • Founded:
  • Website:

Pages

  • Page 1

    Form 5500 Annual Return/Report of Employee Benefit Plan OMB Nos. 1210-0110 1210-0089 This form is required to be filed for employee benefit plans under sections 104 Department of the Treasury and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and Internal Revenue Service sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code). Department of Labor 2014 Employee Benefits Security  Complete all entries in accordance with Administration the instructions to the Form 5500. Pension Benefit Guaranty Corporation This Form is Open to Public Inspection Part I Annual Report Identification Information For calendar plan year 2014 or fiscal plan year beginning 01/01/2014 and ending 12/31/2014 A This return/report is for: X a multiemployer plan; X a multiple-employer plan (Filers checking this box must attach a list of participating employer information in accordance with the form instructions); or X a single-employer plan; X a DFE (specify) _C_ B This return/report is: X the first return/report; X the final return/report; X an amended return/report; X a short plan year return/report (less than 12 months). C If the plan is a collectively-bargained plan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X D Check box if filing under: X Form 5558; X automatic extension; X the DFVC program; X special extension (enter description) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE Part II Basic Plan Information—enter all requested information 1a Name of plan 1b Three-digit plan 505 ABCDEFGHI ABCDEFGHI SETON HALL UNIVERSITY ABCDEFGHI WELFARE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI BENEFIT PROGRAM number (PN)  001 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 1c Effective date of plan YYYY-MM-DD 09/16/1966 2a Plan sponsor’s name and address; include room or suite number (employer, if for a single-employer plan) 2b Employer Identification SETON HALL UNIVERSITY Number (EIN) 012345678 22-1500645 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 2c Plan Sponsor’s telephone D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI number 400 S ORANGE AVENUE ABCDEFGHI 973-761-9181 0123456789 SOUTH ORANGE, NJ 07079-2646 c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 2d Business code (see 123456789 ABCDEFGHI ABCDEFGHI ABCDE instructions) 123456789 ABCDEFGHI ABCDEFGHI ABCDE 012345 611000 CITYEFGHI ABCDEFGHI AB, ST 012345678901 UK Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established. Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules, statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete. SIGN Filed with authorized/valid electronic signature. 09/24/2015 YYYY-MM-DD ROBERT MCLAUGHLIN ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE HERE Signature of plan administrator Date Enter name of individual signing as plan administrator SIGN YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE HERE Signature of employer/plan sponsor Date Enter name of individual signing as employer or plan sponsor SIGN YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE HERE Signature of DFE Date Enter name of individual signing as DFE Preparer’s name (including firm name, if applicable) and address (include room or suite number) (optional) Preparer’s telephone number ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI (optional) ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHIABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Form 5500 (2014) v. 140124


  • Page 2

    Form 5500 (2014) Page 2 3a Plan administrator’s name and address X X Same as Plan Sponsor 3b Administrator’s EIN 012345678 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 3c Administrator’s telephone c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI number 123456789 ABCDEFGHI ABCDEFGHI ABCDE 0123456789 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITYEFGHI ABCDEFGHI AB, ST 012345678901 UK 4 If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the name,4b EIN EIN and the plan number from the last return/report: 012345678 a Sponsor’s name 4c PN ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 012 5 Total number of participants at the beginning of the plan year 5 123456789012 874 6 Number of participants as of the end of the plan year unless otherwise stated (welfare plans complete only lines 6a(1), 6a(2), 6b, 6c, and 6d). a(1) Total number of active participants at the beginning of the plan year ................................................................................ 6a(1) 864 a(2) Total number of active participants at the end of the plan year ....................................................................................... 6a(2) 864 b Retired or separated participants receiving benefits ............................................................................................................. 6b 123456789012 17 c Other retired or separated participants entitled to future benefits.......................................................................................... 6c 1234567890120 d Subtotal. Add lines 6a(2), 6b, and 6c. .................................................................................................................................. 6d 123456789012 881 e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits. ................................................ 6e 123456789012 f Total. Add lines 6d and 6e. ................................................................................................................................................. 6f 123456789012 g Number of participants with account balances as of the end of the plan year (only defined contribution plans complete this item) ............................................................................................................................................................... 6g 123456789012 h Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested ......................................................................................................................................................... 6h 123456789012 7 Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item)......... 7 8a If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codes in the instructions: b If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristics Codes in the instructions: 4A 4B 4D 4E 4L 9a Plan funding arrangement (check all that apply) 9b Plan benefit arrangement (check all that apply) (1) XX Insurance (1) X X Insurance (2) X Code section 412(e)(3) insurance contracts (2) X Code section 412(e)(3) insurance contracts (3) X Trust (3) X Trust (4) XX General assets of the sponsor (4) X X General assets of the sponsor 10 Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions) a Pension Schedules b General Schedules (1) X R (Retirement Plan Information) (1) X H (Financial Information) (2) X MB (Multiemployer Defined Benefit Plan and Certain Money (2) X I (Financial Information – Small Plan) Purchase Plan Actuarial Information) - signed by the plan (3) X X ___ 3 A (Insurance Information) actuary (4) X C (Service Provider Information) (3) X SB (Single-Employer Defined Benefit Plan Actuarial (5) X D (DFE/Participating Plan Information) Information) - signed by the plan actuary (6) X G (Financial Transaction Schedules)


  • Page 3

    Form 5500 (2014) Page 3 Part III Form M-1 Compliance Information (to be completed by welfare benefit plans) 11a If the plan provides welfare benefits, was the plan subject to the Form M-1 filing requirements during the plan year? (See instructions and 29 CFR 2520.101-2.) ........................………..…. Yes X No If “Yes” is checked, complete lines 11b and 11c. 11b Is the plan currently in compliance with the Form M-1 filing requirements? (See instructions and 29 CFR 2520.101-2.) ……..... Yes No 11c Enter the Receipt Confirmation Code for the 2014 Form M-1 annual report. If the plan was not required to file the 2014 Form M-1 annual report, enter the Receipt Confirmation Code for the most recent Form M-1 that was required to be filed under the Form M-1 filing requirements. (Failure to enter a valid Receipt Confirmation Code will subject the Form 5500 filing to rejection as incomplete.) Receipt Confirmation Code______________________


  • Page 4

    SCHEDULE A Insurance Information OMB No. 1210-0110 (Form 5500) Department of the Treasury Internal Revenue Service This schedule is required to be filed under section 104 of the 2014 Employee Retirement Income Security Act of 1974 (ERISA). Department of Labor Employee Benefits Security Administration  File as an attachment to Form 5500. This Form is Open to Public Pension Benefit Guaranty Corporation  Insurance companies are required to provide the information Inspection pursuant to ERISA section 103(a)(2). For calendar plan year 2014 or fiscal plan year beginning 01/01/2014 and ending 12/31/2014 A Name of plan B Three-digit SETON HALL UNIVERSITY WELFARE BENEFIT PROGRAM 505 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE plan number (PN)  001 FGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI C Plan sponsor’s name as shown on line 2a of Form 5500 D Employer Identification Number (EIN) SETON HALL UNIVERSITY ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 22-1500645 012345678 FGHI ABCDEFGHI Part I Information Concerning Insurance Contract Coverage, Fees, and Commissions Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be reported on a single Schedule A. 1 Coverage Information: (a) Name of insurance carrier ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (e) Approximate number of Policy or contract year (c) NAIC (d) Contract or (b) EIN persons covered at end of code identification number (f) From (g) To policy or contract year 59-1031071 012345678 67369 ABCDE 3334085 ABCDE0123456789 1234567 866 01/01/2014 YYYY-MM-DD 12/31/2014 YYYY-MM-DD 2 Insurance fee and commission information. Enter the total fees and total commissions paid. List in line 3 the agents, brokers, and other persons in descending order of the amount paid. (a) Total amount of commissions paid (b) Total amount of fees paid 7397 123456789012345 70545 123456789012345 3 Persons receiving commissions and fees. (Complete as many entries as needed to report all persons). (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI MERCER HEALTH ABCDEFGHI AND BENEFITS, LLC ABCDE 4565 PAYSPHERE CIRCLE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CHICAGO, IL 60674 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid commissions paid (c) Amount (d) Purpose (e) Organization code -123456789012345 7397 -123456789012345 ABCDEFGHI 67882 BENEFIT ABCDEFGHI ADVISOR PAYMENTS ABCDEFGHI 31 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI MERCER HEALTH ABCDEFGHI AND BENEFITS, LLC ABCDE 4565 PAYSPHERE CIRCLE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CHICAGO, IL 60674 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid commissions paid (c) Amount (d) Purpose (e) Organization code -123456789012345 -123456789012345 ABCDEFGHI 2663 GENERAL ABCDEFGHI AGENT PAYMENTS ABCDEFGHI 31 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Schedule A (Form 5500) 2014 v. 140124


  • Page 5

    Schedule A (Form 5500) 2014 Page 2 - 11 x (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


  • Page 6

    Schedule A (Form 5500) 2014 Page 3 Part II Investment and Annuity Contract Information Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 4 Current value of plan’s interest under this contract in the general account at year end .................................................. 4 -123456789012345 5 Current value of plan’s interest under this contract in separate accounts at year end .................................................... 5 -123456789012345 6 Contracts With Allocated Funds: a State the basis of premium rates  b Premiums paid to carrier....................................................................................................................................... 6b -123456789012345 c Premiums due but unpaid at the end of the year ................................................................................................... 6c -123456789012345 d If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or 6d -123456789012345 retention of the contract or policy, enter amount. .................................................................................................. Specify nature of costs  e Type of contract: (1) X individual policies (2) X group deferred annuity (3) X other (specify)  f If contract purchased, in whole or in part, to distribute benefits from a terminating plan, check here  X 7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts) a Type of contract: (1) X deposit administration (2) X immediate participation guarantee (3) X guaranteed investment (4) X other  b Balance at the end of the previous year................................................................................................................ 7b -123456789012345 c Additions: (1) Contributions deposited during the year .................................. 7c(1) -123456789012345 (2) Dividends and credits ............................................................................... 7c(2) -123456789012345 (3) Interest credited during the year ............................................................... 7c(3) -123456789012345 (4) Transferred from separate account........................................................... 7c(4) -123456789012345 (5) Other (specify below) ............................................................................... 7c(5) -123456789012345  (6)Total additions ................................................................................................................................................... 7c(6) -123456789012345 d Total of balance and additions (add lines 7b and 7c(6)). ....................................................................................... 7d -123456789012345 e Deductions: (1) Disbursed from fund to pay benefits or purchase annuities during year 7e(1) -123456789012345 (2) Administration charge made by carrier ...................................................... 7e(2) -123456789012345 (3) Transferred to separate account................................................................ 7e(3) -123456789012345 (4) Other (specify below) ................................................................................ 7e(4) -123456789012345  (5) Total deductions ................................................................................................................................................ 7e(5) -123456789012345 f Balance at the end of the current year (subtract line 7e(5) from line 7d) ............................................................... 7f -123456789012345


  • Page 7

    Schedule A (Form 5500) 2014 Page 4 Part III Welfare Benefit Contract Information If more than one contract covers the same group of employees of the same employer(s) or members of the same employee organizations(s), the information may be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 8 Benefit and contract type (check all applicable boxes) a XX Health (other than dental or vision) bXX Dental cXX Vision d X Life insurance e X Temporary disability (accident and sickness) f X Long-term disability g X Supplemental unemployment h X Prescription drug i X Stop loss (large deductible) j X HMO contract k X PPO contract lXX Indemnity contract m X Other (specify)  ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE 9 Experience-rated contracts: a Premiums: (1) Amount received................................................................... 9a(1) -123456789012345 (2) Increase (decrease) in amount due but unpaid ...................................... 9a(2) -123456789012345 (3) Increase (decrease) in unearned premium reserve ............................... 9a(3) -123456789012345 (4) Earned ((1) + (2) - (3)) .................................................................................................................................. 9a(4) -123456789012345 b Benefit charges (1) Claims paid ................................................................. 9b(1) -123456789012345 (2) Increase (decrease) in claim reserves ................................................... 9b(2) -123456789012345 (3) Incurred claims (add (1) and (2)) .................................................................................................................. 9b(3) 123456789012345 (4) Claims charged ............................................................................................................................................ 9b(4) 123456789012345 c Remainder of premium: (1) Retention charges (on an accrual basis) -- -123456789012345 (A) Commissions ................................................................................. 9c(1)(A) -123456789012345 (B) Administrative service or other fees ................................................ 9c(1)(B) -123456789012345 (C) Other specific acquisition costs ...................................................... 9c(1)(C) -123456789012345 (D) Other expenses.............................................................................. 9c(1)(D) -123456789012345 (E) Taxes ............................................................................................. 9c(1)(E) -123456789012345 (F) Charges for risks or other contingencies ......................................... 9c(1)(F) -123456789012345 (G) Other retention charges ................................................................. 9c(1)(G) -123456789012345 (H) Total retention ....................................................................................................................................... 9c(1)(H) -123456789012345 (2) Dividends or retroactive rate refunds. (These amounts were X paid in cash, or X credited.) .................... 9c(2) -123456789012345 d Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement ................. 9d(1) -123456789012345 (2) Claim reserves ............................................................................................................................................ 9d(2) -123456789012345 (3) Other reserves............................................................................................................................................. 9d(3) -123456789012345 e Dividends or retroactive rate refunds due. (Do not include amount entered in line 9c(2).) ................................ 9e -123456789012345 10 Nonexperience-rated contracts: a Total premiums or subscription charges paid to carrier ..................................................................................... 10a -123456789012345 12292485 b If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, other than reported in Part I, line 2 above, report amount............................. 10b -123456789012345 Specify nature of costs  Part IV Provision of Information 11 Did the insurance company fail to provide any information necessary to complete Schedule A? ............ X Yes X X No 12 If the answer to line 11 is “Yes,” specify the information not provided.  ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


  • Page 8

    SCHEDULE A Insurance Information OMB No. 1210-0110 (Form 5500) Department of the Treasury Internal Revenue Service This schedule is required to be filed under section 104 of the 2014 Employee Retirement Income Security Act of 1974 (ERISA). Department of Labor Employee Benefits Security Administration  File as an attachment to Form 5500. This Form is Open to Public Pension Benefit Guaranty Corporation  Insurance companies are required to provide the information Inspection pursuant to ERISA section 103(a)(2). For calendar plan year 2014 or fiscal plan year beginning 01/01/2014 and ending 12/31/2014 A Name of plan B Three-digit SETON HALL UNIVERSITY WELFARE BENEFIT PROGRAM 505 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE plan number (PN)  001 FGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI C Plan sponsor’s name as shown on line 2a of Form 5500 D Employer Identification Number (EIN) SETON HALL UNIVERSITY ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 22-1500645 012345678 FGHI ABCDEFGHI Part I Information Concerning Insurance Contract Coverage, Fees, and Commissions Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be reported on a single Schedule A. 1 Coverage Information: (a) Name of insurance carrier ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI HARTFORD LIFE AND ACCIDENT (e) Approximate number of Policy or contract year (c) NAIC (d) Contract or (b) EIN persons covered at end of code identification number (f) From (g) To policy or contract year 06-0838648 012345678 70815 ABCDE 208165G ABCDE0123456789 1234567 1262 01/01/2014 YYYY-MM-DD 12/31/2014 YYYY-MM-DD 2 Insurance fee and commission information. Enter the total fees and total commissions paid. List in line 3 the agents, brokers, and other persons in descending order of the amount paid. (a) Total amount of commissions paid (b) Total amount of fees paid 7413 123456789012345 3851 123456789012345 3 Persons receiving commissions and fees. (Complete as many entries as needed to report all persons). (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI MERCER HEALTH ABCDEFGHI AND BENEFITS, LLC ABCDE 4565 PAYSPHERE CIRCLE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CHICAGO, IL 60674 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid commissions paid (c) Amount (d) Purpose (e) Organization code -123456789012345 7413 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 31 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI MERCER HUMAN RESOURCE ABCDEFGHI ABCDE 4565 PAYSPHERE CIRCLE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CHICAGO, IL 60674 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid commissions paid (c) Amount (d) Purpose (e) Organization code -123456789012345 -123456789012345 ABCDEFGHI 3851 ADDITIONAL ABCDEFGHI ABCDEFGHI COMPENSATION 31 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Schedule A (Form 5500) 2014 v. 140124


  • Page 9

    Schedule A (Form 5500) 2014 Page 2 - 11 x (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


  • Page 10

    Schedule A (Form 5500) 2014 Page 3 Part II Investment and Annuity Contract Information Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 4 Current value of plan’s interest under this contract in the general account at year end .................................................. 4 -123456789012345 5 Current value of plan’s interest under this contract in separate accounts at year end .................................................... 5 -123456789012345 6 Contracts With Allocated Funds: a State the basis of premium rates  b Premiums paid to carrier....................................................................................................................................... 6b -123456789012345 c Premiums due but unpaid at the end of the year ................................................................................................... 6c -123456789012345 d If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or 6d -123456789012345 retention of the contract or policy, enter amount. .................................................................................................. Specify nature of costs  e Type of contract: (1) X individual policies (2) X group deferred annuity (3) X other (specify)  f If contract purchased, in whole or in part, to distribute benefits from a terminating plan, check here  X 7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts) a Type of contract: (1) X deposit administration (2) X immediate participation guarantee (3) X guaranteed investment (4) X other  b Balance at the end of the previous year................................................................................................................ 7b -123456789012345 c Additions: (1) Contributions deposited during the year .................................. 7c(1) -123456789012345 (2) Dividends and credits ............................................................................... 7c(2) -123456789012345 (3) Interest credited during the year ............................................................... 7c(3) -123456789012345 (4) Transferred from separate account........................................................... 7c(4) -123456789012345 (5) Other (specify below) ............................................................................... 7c(5) -123456789012345  (6)Total additions ................................................................................................................................................... 7c(6) -123456789012345 d Total of balance and additions (add lines 7b and 7c(6)). ....................................................................................... 7d -123456789012345 e Deductions: (1) Disbursed from fund to pay benefits or purchase annuities during year 7e(1) -123456789012345 (2) Administration charge made by carrier ...................................................... 7e(2) -123456789012345 (3) Transferred to separate account................................................................ 7e(3) -123456789012345 (4) Other (specify below) ................................................................................ 7e(4) -123456789012345  (5) Total deductions ................................................................................................................................................ 7e(5) -123456789012345 f Balance at the end of the current year (subtract line 7e(5) from line 7d) ............................................................... 7f -123456789012345


  • Page 11

    Schedule A (Form 5500) 2014 Page 4 Part III Welfare Benefit Contract Information If more than one contract covers the same group of employees of the same employer(s) or members of the same employee organizations(s), the information may be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 8 Benefit and contract type (check all applicable boxes) a X Health (other than dental or vision) b X Dental c X Vision dXX Life insurance e X Temporary disability (accident and sickness) f X Long-term disability g X Supplemental unemployment h X Prescription drug i X Stop loss (large deductible) j X HMO contract k X PPO contract l X Indemnity contract mX X Other (specify) ACCIDENTAL ABCDEFGHI ABCDEFGHI DEATH ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI AND DISMEMBERMENT ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE 9 Experience-rated contracts: a Premiums: (1) Amount received................................................................... 9a(1) -123456789012345 (2) Increase (decrease) in amount due but unpaid ...................................... 9a(2) -123456789012345 (3) Increase (decrease) in unearned premium reserve ............................... 9a(3) -123456789012345 (4) Earned ((1) + (2) - (3)) .................................................................................................................................. 9a(4) -123456789012345 b Benefit charges (1) Claims paid ................................................................. 9b(1) -123456789012345 (2) Increase (decrease) in claim reserves ................................................... 9b(2) -123456789012345 (3) Incurred claims (add (1) and (2)) .................................................................................................................. 9b(3) 123456789012345 (4) Claims charged ............................................................................................................................................ 9b(4) 123456789012345 c Remainder of premium: (1) Retention charges (on an accrual basis) -- -123456789012345 (A) Commissions ................................................................................. 9c(1)(A) -123456789012345 (B) Administrative service or other fees ................................................ 9c(1)(B) -123456789012345 (C) Other specific acquisition costs ...................................................... 9c(1)(C) -123456789012345 (D) Other expenses.............................................................................. 9c(1)(D) -123456789012345 (E) Taxes ............................................................................................. 9c(1)(E) -123456789012345 (F) Charges for risks or other contingencies ......................................... 9c(1)(F) -123456789012345 (G) Other retention charges ................................................................. 9c(1)(G) -123456789012345 (H) Total retention ....................................................................................................................................... 9c(1)(H) -123456789012345 (2) Dividends or retroactive rate refunds. (These amounts were X paid in cash, or X credited.) .................... 9c(2) -123456789012345 d Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement ................. 9d(1) -123456789012345 (2) Claim reserves ............................................................................................................................................ 9d(2) -123456789012345 (3) Other reserves............................................................................................................................................. 9d(3) -123456789012345 e Dividends or retroactive rate refunds due. (Do not include amount entered in line 9c(2).) ................................ 9e -123456789012345 10 Nonexperience-rated contracts: a Total premiums or subscription charges paid to carrier ..................................................................................... 10a -123456789012345 307763 b If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, other than reported in Part I, line 2 above, report amount............................. 10b -123456789012345 Specify nature of costs  Part IV Provision of Information 11 Did the insurance company fail to provide any information necessary to complete Schedule A? ............ X Yes X X No 12 If the answer to line 11 is “Yes,” specify the information not provided.  ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


  • Page 12

    SCHEDULE A Insurance Information OMB No. 1210-0110 (Form 5500) Department of the Treasury Internal Revenue Service This schedule is required to be filed under section 104 of the 2014 Employee Retirement Income Security Act of 1974 (ERISA). Department of Labor Employee Benefits Security Administration  File as an attachment to Form 5500. This Form is Open to Public Pension Benefit Guaranty Corporation  Insurance companies are required to provide the information Inspection pursuant to ERISA section 103(a)(2). For calendar plan year 2014 or fiscal plan year beginning 01/01/2014 and ending 12/31/2014 A Name of plan B Three-digit SETON HALL UNIVERSITY WELFARE BENEFIT PROGRAM 505 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE plan number (PN)  001 FGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI C Plan sponsor’s name as shown on line 2a of Form 5500 D Employer Identification Number (EIN) SETON HALL UNIVERSITY ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 22-1500645 012345678 FGHI ABCDEFGHI Part I Information Concerning Insurance Contract Coverage, Fees, and Commissions Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be reported on a single Schedule A. 1 Coverage Information: (a) Name of insurance carrier ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI HARTFORD LIFE AND ACCIDENT (e) Approximate number of Policy or contract year (c) NAIC (d) Contract or (b) EIN persons covered at end of code identification number (f) From (g) To policy or contract year 06-0838648 012345678 70815 ABCDE ADD-S02063 ABCDE0123456789 1234567 106 01/01/2014 YYYY-MM-DD 12/31/2014 YYYY-MM-DD 2 Insurance fee and commission information. Enter the total fees and total commissions paid. List in line 3 the agents, brokers, and other persons in descending order of the amount paid. (a) Total amount of commissions paid (b) Total amount of fees paid 1607 123456789012345 0 123456789012345 3 Persons receiving commissions and fees. (Complete as many entries as needed to report all persons). (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI MERCER HEALTH ABCDEFGHI AND BENEFITS, LLC ABCDE 4565 PAYSPHERE CIRCLE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CHICAGO, IL 60674 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid commissions paid (c) Amount (d) Purpose (e) Organization code -123456789012345 1607 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 31 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid commissions paid (c) Amount (d) Purpose (e) Organization code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Schedule A (Form 5500) 2014 v. 140124


  • Page 13

    Schedule A (Form 5500) 2014 Page 2 - 11 x (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 (b) Amount of sales and base Fees and other commissions paid (e) Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


  • Page 14

    Schedule A (Form 5500) 2014 Page 3 Part II Investment and Annuity Contract Information Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 4 Current value of plan’s interest under this contract in the general account at year end .................................................. 4 -123456789012345 5 Current value of plan’s interest under this contract in separate accounts at year end .................................................... 5 -123456789012345 6 Contracts With Allocated Funds: a State the basis of premium rates  b Premiums paid to carrier....................................................................................................................................... 6b -123456789012345 c Premiums due but unpaid at the end of the year ................................................................................................... 6c -123456789012345 d If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or 6d -123456789012345 retention of the contract or policy, enter amount. .................................................................................................. Specify nature of costs  e Type of contract: (1) X individual policies (2) X group deferred annuity (3) X other (specify)  f If contract purchased, in whole or in part, to distribute benefits from a terminating plan, check here  X 7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts) a Type of contract: (1) X deposit administration (2) X immediate participation guarantee (3) X guaranteed investment (4) X other  b Balance at the end of the previous year................................................................................................................ 7b -123456789012345 c Additions: (1) Contributions deposited during the year .................................. 7c(1) -123456789012345 (2) Dividends and credits ............................................................................... 7c(2) -123456789012345 (3) Interest credited during the year ............................................................... 7c(3) -123456789012345 (4) Transferred from separate account........................................................... 7c(4) -123456789012345 (5) Other (specify below) ............................................................................... 7c(5) -123456789012345  (6)Total additions ................................................................................................................................................... 7c(6) -123456789012345 d Total of balance and additions (add lines 7b and 7c(6)). ....................................................................................... 7d -123456789012345 e Deductions: (1) Disbursed from fund to pay benefits or purchase annuities during year 7e(1) -123456789012345 (2) Administration charge made by carrier ...................................................... 7e(2) -123456789012345 (3) Transferred to separate account................................................................ 7e(3) -123456789012345 (4) Other (specify below) ................................................................................ 7e(4) -123456789012345  (5) Total deductions ................................................................................................................................................ 7e(5) -123456789012345 f Balance at the end of the current year (subtract line 7e(5) from line 7d) ............................................................... 7f -123456789012345


  • Page 15

    Schedule A (Form 5500) 2014 Page 4 Part III Welfare Benefit Contract Information If more than one contract covers the same group of employees of the same employer(s) or members of the same employee organizations(s), the information may be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 8 Benefit and contract type (check all applicable boxes) a X Health (other than dental or vision) b X Dental c X Vision d X Life insurance e X Temporary disability (accident and sickness) f X Long-term disability g X Supplemental unemployment h X Prescription drug i X Stop loss (large deductible) j X HMO contract k X PPO contract l X Indemnity contract mX X Other (specify) ACCIDENTAL ABCDEFGHI ABCDEFGHI DEATH ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI AND DISMEMBERMENT ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE 9 Experience-rated contracts: a Premiums: (1) Amount received................................................................... 9a(1) -123456789012345 (2) Increase (decrease) in amount due but unpaid ...................................... 9a(2) -123456789012345 (3) Increase (decrease) in unearned premium reserve ............................... 9a(3) -123456789012345 (4) Earned ((1) + (2) - (3)) .................................................................................................................................. 9a(4) -123456789012345 b Benefit charges (1) Claims paid ................................................................. 9b(1) -123456789012345 (2) Increase (decrease) in claim reserves ................................................... 9b(2) -123456789012345 (3) Incurred claims (add (1) and (2)) .................................................................................................................. 9b(3) 123456789012345 (4) Claims charged ............................................................................................................................................ 9b(4) 123456789012345 c Remainder of premium: (1) Retention charges (on an accrual basis) -- -123456789012345 (A) Commissions ................................................................................. 9c(1)(A) -123456789012345 (B) Administrative service or other fees ................................................ 9c(1)(B) -123456789012345 (C) Other specific acquisition costs ...................................................... 9c(1)(C) -123456789012345 (D) Other expenses.............................................................................. 9c(1)(D) -123456789012345 (E) Taxes ............................................................................................. 9c(1)(E) -123456789012345 (F) Charges for risks or other contingencies ......................................... 9c(1)(F) -123456789012345 (G) Other retention charges ................................................................. 9c(1)(G) -123456789012345 (H) Total retention ....................................................................................................................................... 9c(1)(H) -123456789012345 (2) Dividends or retroactive rate refunds. (These amounts were X paid in cash, or X credited.) .................... 9c(2) -123456789012345 d Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement ................. 9d(1) -123456789012345 (2) Claim reserves ............................................................................................................................................ 9d(2) -123456789012345 (3) Other reserves............................................................................................................................................. 9d(3) -123456789012345 e Dividends or retroactive rate refunds due. (Do not include amount entered in line 9c(2).) ................................ 9e -123456789012345 10 Nonexperience-rated contracts: a Total premiums or subscription charges paid to carrier ..................................................................................... 10a -123456789012345 10711 b If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, other than reported in Part I, line 2 above, report amount............................. 10b -123456789012345 Specify nature of costs  Part IV Provision of Information 11 Did the insurance company fail to provide any information necessary to complete Schedule A? ............ X Yes X X No 12 If the answer to line 11 is “Yes,” specify the information not provided.  ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE


  • Page 16

    Form 5500 Annual Return/Report of Employee Benefit Plan OMB Nos. 1210-0110 1210-0089 This form is required to be filed for employee benefit plans under sections 104 Departmentof the Treasury and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and Internal Revenue Service sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code). Department of Labor 2014 Employee Benefits Security » Completeall entries in accordance with Administration the instructions to the Form 5500. Pension Benefit Guaranty Corporation This Form is Open to Public Inspection Part | | Annual Report Identification Information For calendar plan year 2014 or fiscal plan year beginning 01/01/2014 and ending 12/31/2014 A This return/report is for: [] a multiemployer plan; a multiple-employer plan (Filers checking this box must attach a list of participating employer information in accordance with the form instructions); or Kl a single-employer plan; N] a DFE (specify) B This return/report is: [] the first return/report; [] the final return/report; [| an amended return/report: [] a short plan year return/report (less than 12 months). C Ifthe plan is a collectively-bargained plan, check here... ccc eene eee ee eevee, » bd D Checkbox iffiling under: id Form 5558; J automatic extension; O the DFVC program; 1] special extension (enter description) Part Il | Basic Plan Information—enter all requested information 1a Name of plan 1b Three-digit plan number (PN) » SAS Seton Hall University Welfare Benefit Program 1C Effective date of plan 09/16/1966 2a Plan sponsor's name and address; include room or suite number (employer, if for a single-employer plan) 2b Employer Identification Number (EIN) Seton Hall University 22-1500645 2C Plan Sponsor's telephone number 400 S Orange Avenue (973) 761-9181 2d Business code (see South Orange NJ 07079-2646 instructions) 611000 Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable causeis established. Under penalties of perjury and other penalties set forth in the instructions, | declare that | have examinedthis return/report, including accompanying schedules, statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief,it is true, correct, and complete. en Al? Ubi Signature ofp plan admfnistrator glo|kogger MLpresti Bate / — € . Enter name of individual signing as plan administrator SIGN HERE Signature of employer/plan sponsor Date Enter name ofindividual signing as employeror plan sponsor SIGN HERE Signature of DFE Date Enter name of individual signing as DFE Preparer's name (including firm name, if applicable) and address (include room or suite number) (optional) Preparer's telephone number (optional) For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Form 5500 (2014) v. 140124


  • Page 17

    Form 5500 (2014) Page 2 3a Plan administrator's name and address [Same as Plan Sponsor 3b Administrator's EIN 3c Administrator's telephone number 4 _Ifthe name and/or EIN of the plan sponsor has changed sincethe last return/report filed for this plan, enter the name, 4b EIN EIN and the plan number from the last return/report: A Sponsor's name 4c PN 5 Total numberofparticipants at the beginning of the plan year 5 | 874 6 Number ofparticipants as of the end ofthe plan year unlessotherwise stated (welfare plans complete only lines 6a(1), 6a(2), 6b, 6c, and 6d). a(1) Total number of active participants at the beginning of the plan year................... eeen eneen eere eeenend 6a(1) 864 a(2) Total numberof active participants at the end of the Plan year ..........ecessesecsessessessssessesvessssnetscsassesveeessvssvenssstenseneeseesceees 6a(2) 864 b Retired or separated participants receiving DENEfÌtS................................... ieri OD 17 C Other retired or separatedparticipants entitled to future benefits. OC 0 d Subtotal. Add lines Ba(2), 6b, and 6e. … eneen nennen enen evers enen eversernenn vennen eenen verneveenendavernen 6d 881 @ Deceased participants whose beneficiaries are receiving or are entitled to receive benefits. nnn 60 f Total. Add lines 6d and 6e. … nnen eenen ro rre nene raros 6f Q Number ofparticipants with account balances as of the end of the plan year (only defined contribution plans complete this item) … cececcsceceessessersussneesessessescnessessneceessvqeasvssssssessssssusssussuecasesuessesuesyesusearsantqursanscersiessatanseasveneeessenecesseee 6g h_ Numberofparticipants that terminated employment during the plan year with accrued benefits that were less than 100% vested A ON 7 Enter the total number of employers obligated to contribute to the plan (only multiemployer plans completethis item)...... 7 8a If the pian provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codesin the instructions: b Ifthe plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristics Codes in the instructions: 4K 4B 4D 4E AL 9a Plan funding arrangement (checkall that apply) 9b Plan benefit arrangement(checkall that apply) (1) Insurance (1) (2) Code section 412(e)(3) insurance contracts (2) (3) Trust (3) (4) General assets of the sponsor (4) 10 Checkall applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached. (Seeinstructions) a Pension Schedules b General Schedules (1) (J R (Retirement Plan Information) (1) O H (Financial Information) (2) [] MB (Multiemployer Defined Benefit Plan and Certain Money (2) | (Financial Information — Small Plan) Purchase Plan Actuarial Information) - signed bythe plan (3) _3 A (Insurance Information) actuary (4) C (Service Provider Information) (3) [] SB (Single-Employer Defined Benefit Plan Actuarial (5) D (DFE/Participating Plan Information) Information) - signed by the plan actuary (6) [] G (Financial Transaction Schedules)


  • Page 18

  • View More

Get the full picture and Receive alerts on lawsuits, news articles, publications and more!