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  • Page 1

    Form 5500 Annual Return/Report of Employee Benefit Plan OMB Nos. 1210-0110 1210-0089 Department of the Treasury This form is required to be filed for employee benefit plans under sections 104 Internal Revenue Service and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and Department of Labor sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code). Employee Benefits Security 2015 Administration  Complete all entries in accordance with Pension Benefit Guaranty Corporation the instructions to the Form 5500. This Form is Open to Public Inspection Part I Annual Report Identification Information For calendar plan year 2015 or fiscal plan year beginning 01/01/2015 and ending 12/31/2015 X a multiemployer plan; X a multiple-employer plan (Filers checking this box must attach a list of A This return/report is for: 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 number (PN)  506 001 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI SETON HALL UNIVERSITY ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 1c Effective date of plan 01/01/2015 YYYY-MM-DD 2a Plan sponsor’s name (employer, if for a single-employer plan) 2b Employer Identification Mailing address (include room, apt., suite no. and street, or P.O. Box) Number (EIN) City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions) 22-1500645 012345678 SETON HALL UNIVERSITY ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 2c Plan Sponsor’s telephone D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI number ABCDEFGHI 973-761-9181 0123456789 c/oS ORANGE 400 ABCDEFGHI AVE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 400 S ORANGE AVE ABCDEFGHI ABCDEFGHI 2d Business code (see SOUTH ORANGE, 123456789 NJ 07079-2646ABCDEFGHI ABCDE ABCDEFGHI SOUTH ORANGE, NJ 07079-2646 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. 03/11/2016 YYYY-MM-DD MICHAEL SILVESTRO ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE HERE Signature of plan administrator Date Enter name of individual signing as plan administrator SIGN Filed with authorized/valid electronic signature. 03/11/2016 YYYY-MM-DD MICHAEL SILVESTRO 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) ABCDEFGHI Preparer’s telephone number 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 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 (2015) v. 150123


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    Form 5500 (2015) Page 2 3a X Same as Plan Sponsor Plan administrator’s name and address X 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 1275 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) 1275 a(2) Total number of active participants at the end of the plan year .......................................................................................... 6a(2) 1337 b Retired or separated participants receiving benefits................................................................................................................. 6b 123456789012 c Other retired or separated participants entitled to future benefits............................................................................................. 6c 123456789012 d Subtotal. Add lines 6a(2), 6b, and 6c. ...................................................................................................................................... 6d 123456789012 1337 e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits. .................................................. 6e 123456789012 f Total. Add lines 6d and 6e. ...................................................................................................................................................... 6f 123456789012 1337 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: 4H 9a Plan funding arrangement (check all that apply) 9b Plan benefit arrangement (check all that apply) (1) X Insurance (1) 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) X General assets of the sponsor (4) 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 1 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 (2015) 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.) ........................………..…. X 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.) ……..... X Yes X No 11c Enter the Receipt Confirmation Code for the 2015 Form M-1 annual report. If the plan was not required to file the 2015 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______________________


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    SCHEDULE A Insurance Information OMB No. 1210-0110 (Form 5500) Department of the Treasury This schedule is required to be filed under section 104 of the Internal Revenue Service Employee Retirement Income Security Act of 1974 (ERISA). 2015 Department of Labor Employee Benefits Security Administration  File as an attachment to Form 5500. Pension Benefit Guaranty Corporation  Insurance companies are required to provide the information This Form is Open to Public pursuant to ERISA section 103(a)(2). Inspection For calendar plan year 2015 or fiscal plan year beginning 01/01/2015 and ending 12/31/2015 A Name of plan B Three-digit SETON HALL UNIVERSITY ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE plan number (PN)  506 001 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) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE SETON HALL UNIVERSITY 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 LIFE INSURANCEABCDEFGHI COMPANY OF ABCDEFGHI ABCDEFGHI NORTH AMERICA ABCDEFGHI ABCDEFGHI ABCDEFGHI (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 23-1503749 65498 FLK960856 1337 01/01/2015 12/31/2015 012345678 ABCDE ABCDE0123456789 1234567 YYYY-MM-DD 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 25386 123456789012345 4375 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 JAMES ABCDEFGHI R. NELLIGAN ABCDEFGHI ABCDE & ASSOCIATES 11 MARISSA DRIVE 123456789 ABCDEFGHI ABCDEFGHI ABCDE NEW EGYPT, NJ 08533 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 0 -123456789012345 ABCDEFGHI 4375 SALES ABCDEFGHI & SERVICE ABCDEFGHI SUPPLE/OVERRIDE 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 MEEKER ABCDEFGHI SHARKEY ABCDEFGHI ASSOCIATES LLC ABCDE 21 COMMERCE DRIVE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CRANFORD, NJ 07016 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 Fees and other commissions paid (b) Amount of sales and base commissions paid (c) Amount (d) Purpose (e) Organization code -123456789012345 25386 -123456789012345 ABCDEFGHI 0 SALES ABCDEFGHI & SERVICE ABCDEFGHI SUPPLE/OVERRIDE 3 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) 2015 v. 150123


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    Schedule A (Form 5500) 2015 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


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    Schedule A (Form 5500) 2015 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 7b Balance at the end of the previous year ................................................................................................................... -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


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    Schedule A (Form 5500) 2015 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) bX Dental cX Vision dX Life insurance e X Temporary disability (accident and sickness) f X Long-term disability gX Supplemental unemployment hX Prescription drug i X Stop loss (large deductible) j X HMO contract kX PPO contract lX Indemnity contract mX 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 253861 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 No X 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


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