GROUP LIFE AND AD&D INSURANCE
|
2021
|
161226757
|
2022-07-20
|
ADVANCED BUSINESS MACHINES INC
|
52
|
|
Three-digit plan number (PN) |
507
|
Effective date of plan |
2021-01-01
|
Business code |
423400
|
Sponsor’s telephone number |
7166313345
|
Plan
sponsor’s DBA name |
LINEAGE
|
Plan sponsor’s mailing address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan sponsor’s
address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan administrator’s name and address
Administrator’s EIN |
131898173 |
Plan administrator’s name |
FIRST UNUM LIFE INSURANCE COMPANY |
Plan administrator’s
address |
PO BOX 100158, COLUMBIA, SC, 292023158 |
Administrator’s telephone number |
8666793054 |
Number of participants as of the end of the plan year
Active participants |
97 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2022-07-20 |
Name of individual signing |
DAVID HILLERY |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
VOLUNTARY AD&D INSURANCE
|
2021
|
161226757
|
2022-07-20
|
ADVANCED BUSINESS MACHINES INC
|
52
|
|
Three-digit plan number (PN) |
506
|
Effective date of plan |
2021-01-01
|
Business code |
423400
|
Sponsor’s telephone number |
7166313345
|
Plan
sponsor’s DBA name |
LINEAGE
|
Plan sponsor’s mailing address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan sponsor’s
address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan administrator’s name and address
Administrator’s EIN |
131898173 |
Plan administrator’s name |
FIRST UNUM LIFE INSURANCE COMPANY |
Plan administrator’s
address |
PO BOX 100158, COLUMBIA, SC, 292023158 |
Administrator’s telephone number |
8666793054 |
Number of participants as of the end of the plan year
Active participants |
58 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2022-07-20 |
Name of individual signing |
DAVID HILLERY |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
HEALTH AND PRESCRIPTION INSURANCE
|
2021
|
161226757
|
2022-07-20
|
ADVANCED BUSINESS MACHINES INC
|
52
|
|
Three-digit plan number (PN) |
502
|
Effective date of plan |
2021-01-01
|
Business code |
423400
|
Sponsor’s telephone number |
7166313345
|
Plan
sponsor’s DBA name |
LINEAGE
|
Plan sponsor’s mailing address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan sponsor’s
address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan administrator’s name and address
Administrator’s EIN |
166443379 |
Plan administrator’s name |
NOVA HEALTHCARE ADMINISTRATORS, INC |
Plan administrator’s
address |
6400 MAIN ST STE 210, WILLIAMSVILLE, NY, 142215803 |
Administrator’s telephone number |
7167731143 |
Number of participants as of the end of the plan year
Active participants |
72 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2022-07-20 |
Name of individual signing |
DAVID HILLERY |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
DENTAL INSURANCE
|
2021
|
161226757
|
2022-07-20
|
ADVANCED BUSINESS MACHINES INC
|
52
|
|
Three-digit plan number (PN) |
502
|
Effective date of plan |
2021-01-01
|
Business code |
423400
|
Sponsor’s telephone number |
7166313345
|
Plan
sponsor’s DBA name |
LINEAGE
|
Plan sponsor’s mailing address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan sponsor’s
address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan administrator’s name and address
Administrator’s EIN |
271395245 |
Plan administrator’s name |
SOLSTICE HEALTH INSURANCE COMPANY |
Plan administrator’s
address |
PO BOX 2057, FARMINGTON HILLS, MI, 483332057 |
Administrator’s telephone number |
8777602247 |
Number of participants as of the end of the plan year
Active participants |
141 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2022-07-20 |
Name of individual signing |
DAVID HILLERY |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
VOLUNTARY SUPPLEMENTARY LIFE INSURANCE
|
2021
|
161226757
|
2022-07-20
|
ADVANCED BUSINESS MACHINES INC
|
52
|
|
Three-digit plan number (PN) |
505
|
Effective date of plan |
2021-01-01
|
Business code |
423400
|
Sponsor’s telephone number |
7166313345
|
Plan
sponsor’s DBA name |
LINEAGE
|
Plan sponsor’s mailing address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan sponsor’s
address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan administrator’s name and address
Administrator’s EIN |
131898173 |
Plan administrator’s name |
FIRST UNUM LIFE INSURANCE COMPANY |
Plan administrator’s
address |
PO BOX 100158, COLUMBIA, SC, 292023158 |
Administrator’s telephone number |
8666793054 |
Number of participants as of the end of the plan year
Active participants |
68 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2022-07-20 |
Name of individual signing |
DAVID HILLERY |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
VOLUNTARY SHORT TERM DISABILITY INSURANCE
|
2021
|
161226757
|
2022-07-20
|
ADVANCED BUSINESS MACHINES INC
|
20
|
|
Three-digit plan number (PN) |
510
|
Effective date of plan |
2021-01-01
|
Business code |
423400
|
Sponsor’s telephone number |
7166313345
|
Plan
sponsor’s DBA name |
LINEAGE
|
Plan sponsor’s mailing address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan sponsor’s
address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan administrator’s name and address
Administrator’s EIN |
131898173 |
Plan administrator’s name |
FIRST UNUM LIFE INSURANCE COMPANY |
Plan administrator’s
address |
PO BOX 100158, COLUMBIA, SC, 292023158 |
Administrator’s telephone number |
8666793054 |
Number of participants as of the end of the plan year
Active participants |
36 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2022-07-20 |
Name of individual signing |
DAVID HILLERY |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
EMPLOYER PAID SHORT TERM DISABILITY INSURANCE
|
2021
|
161226757
|
2022-07-20
|
ADVANCED BUSINESS MACHINES INC
|
52
|
|
Three-digit plan number (PN) |
509
|
Effective date of plan |
2021-01-01
|
Business code |
423400
|
Sponsor’s telephone number |
7166313345
|
Plan
sponsor’s DBA name |
LINEAGE
|
Plan sponsor’s mailing address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan sponsor’s
address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan administrator’s name and address
Administrator’s EIN |
131898173 |
Plan administrator’s name |
FIRST UNUM LIFE INSURANCE COMPANY |
Plan administrator’s
address |
PO BOX 100158, COLUMBIA, SC, 292023158 |
Administrator’s telephone number |
8666793054 |
Number of participants as of the end of the plan year
Active participants |
103 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2022-07-20 |
Name of individual signing |
DAVID HILLERY |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
LONG TERM DISABILITY INSURANCE
|
2021
|
161226757
|
2022-07-20
|
ADVANCED BUSINESS MACHINES INC
|
52
|
|
Three-digit plan number (PN) |
508
|
Effective date of plan |
2021-01-01
|
Business code |
423400
|
Sponsor’s telephone number |
7166313345
|
Plan
sponsor’s DBA name |
LINEAGE
|
Plan sponsor’s mailing address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan sponsor’s
address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan administrator’s name and address
Administrator’s EIN |
131898173 |
Plan administrator’s name |
FIRST UNUM LIFE INSURANCE COMPANY |
Plan administrator’s
address |
PO BOX 100158, COLUMBIA, SC, 292023158 |
Administrator’s telephone number |
8666793054 |
Number of participants as of the end of the plan year
Active participants |
97 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2022-07-20 |
Name of individual signing |
DAVID HILLERY |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
VISION INSURANCE
|
2021
|
161226757
|
2022-07-20
|
ADVANCED BUSINESS MACHINES INC
|
52
|
|
Three-digit plan number (PN) |
504
|
Effective date of plan |
2021-01-01
|
Business code |
423400
|
Sponsor’s telephone number |
7166313345
|
Plan
sponsor’s DBA name |
LINEAGE
|
Plan sponsor’s mailing address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan sponsor’s
address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan administrator’s name and address
Administrator’s EIN |
271395245 |
Plan administrator’s name |
SOLSTICE HEALTH INSURANCE COMPANY |
Plan administrator’s
address |
PO BOX 2057, FARMINGTON HILLS, MI, 483332057 |
Administrator’s telephone number |
8777602247 |
Number of participants as of the end of the plan year
Active participants |
141 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2022-07-20 |
Name of individual signing |
DAVID HILLERY |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
DENTAL INSURANCE
|
2021
|
161226757
|
2022-07-27
|
ADVANCED BUSINESS MACHINES INC
|
52
|
|
File |
View Page
|
Three-digit plan number (PN) |
502
|
Effective date of plan |
2021-01-01
|
Business code |
423400
|
Sponsor’s telephone number |
7166313345
|
Plan
sponsor’s DBA name |
LINEAGE
|
Plan sponsor’s mailing address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan sponsor’s
address |
385 N FRENCH RD, AMHERST, NY, 142282032
|
Plan administrator’s name and address
Administrator’s EIN |
271395245 |
Plan administrator’s name |
SOLSTICE HEALTH INSURANCE COMPANY |
Plan administrator’s
address |
PO BOX 2057, FARMINGTON HILLS, MI, 483332057 |
Administrator’s telephone number |
8777602247 |
Number of participants as of the end of the plan year
Active participants |
141 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2022-07-27 |
Name of individual signing |
DAVID HILLERY |
Valid signature |
Filed with authorized/valid electronic signature |
|
Role |
Employer/plan sponsor |
Date |
2022-07-27 |
Name of individual signing |
DAVID HILLERY |
Valid signature |
Filed with authorized/valid electronic signature |
|
|