MEWA-ECE Form
This Form is Open to Public Inspection
OMB No. 1210-0116
Department of Labor
Employee Benefits Security Administration
Complete as applicable:
02/25/2021
Ziff Brothers Investments L.L.C. Employee Welfare Plan
420 Fifth Avenue, 5th Floor
New York, NY 10018
(212) 292-6000
13-3810050
501
Ziff Brothers Investments L.L.C.
420 Fifth Avenue, 5th Floor
New York, NY 10018
(212) 292-6000
13-3810050
vking@zcp.com
Ziff Brothers Investments L.L.C.
420 Fifth Avenue, 5th Floor
New York, NY 10018
(212) 292-6000
13-3810050
Ziff Brothers Investments L.L.C.
420 Fifth Avenue, 5th Floor
New York, NY 10018
(212) 292-6000
vking@zcp.com
Chris Burkhardt
Ziff Capital Partners
285 Madison Avenue, 20th Floor
New York, NY 10017
(212) 292-6000
cburkhardt@zcp.com
JPMorgan Chase Bank, N.A.
Mail Code: TX1-0062
P.O. Box 955200
Fort Worth, TX 76155-9200
(800) 550-8509
Connecticut General Life Insurance Company
900 Cottage Grove Rd.
Hartford, NY 06152
(860) 226-6000
communityservice@cigna.com
06-0303370
Ziff Brothers Investments L.L.C.
420 Fifth Avenue, 5th Floor
New York, NY 10018
(212) 292-6000
vking@zcp.com
13-3810050
No
Yes
Chubb Group of Insurance Companies
Yes
Yes
If no, please explain.
No
If yes, please identify each litigation or enforcement proceeding to include (if applicable): (1) the case number, (2) the date, (3) the nature of the proceedings, (4) the court, (5) all parties (for example, plaintiffs and defendants or petitioners and respondents), and (6) the disposition.
No
If yes, please explain.
No
Entity | Year |
---|
17a | 17b | 17c | 17d | 17e | 17f | 17g | 17h | 17i | 17j |
---|---|---|---|---|---|---|---|---|---|
Enter all States where the MEWA or ECE is operating. | Is coverage provided? | State registration number. | Name of state agent or entity for service of process. | Is the entity a licensed health insurer in this State? | If yes to 17e, enter NAIC number. | If no to 17e, is the entity fully insured? | If yes to 17g, enter name and NAIC number of insurer. | Does the entity purchase stop loss coverage? | If yes to 17i, enter the name and NAIC number of insurer. |
CA
Is new? |
Yes | No | Yes | Vision Service Plan, NAIC # 47029, Connecticut General Life Insurance Company, NAIC # 62308, First Unum Life Insurance Company, NAIC # 62235 | No | ||||
CO
Is new? |
Yes | No | Yes | Vision Service Plan, NAIC # 47029, Connecticut General Life Insurance Company, NAIC # 62308, First Unum Life Insurance Company, NAIC # 62235 | No | ||||
CT
Is new? |
Yes | No | Yes | Vision Service Plan, NAIC # 47029, Connecticut General Life Insurance Company, NAIC # 62308, First Unum Life Insurance Company, NAIC # 62235 | No | ||||
FL
Is new? |
Yes | No | Yes | Vision Service Plan, NAIC # 47029, Connecticut General Life Insurance Company, NAIC # 62308, First Unum Life Insurance Company, NAIC # 62235 | No | ||||
MA
Is new? |
Yes | No | Yes | Vision Service Plan, NAIC # 47029, Connecticut General Life Insurance Company, NAIC # 62308, First Unum Life Insurance Company, NAIC # 62235 | No | ||||
NY
Is new? |
Yes | No | Yes | Vision Service Plan, NAIC # 47029, Connecticut General Life Insurance Company, NAIC # 62308, First Unum Life Insurance Company, NAIC # 62235 | No | ||||
WA
Is new? |
Yes | No | Yes | Vision Service Plan, NAIC # 47029, Connecticut General Life Insurance Company, NAIC # 62308, First Unum Life Insurance Company, NAIC # 62235 | No |
NY
225
N/A
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Under penalty of perjury and other penalties set forth in the instructions, I declare that I have examined this report, including any accompanying attachments, and to the best of my knowledge and belief, it is true and correct. Under penalty of perjury and other penalties set forth in the instructions, I also declare that, unless this is an extension request, this report is complete.