U.S. Department of Labor
Office of Labor-Management Standards
Washington, DC 20210
FORM LM-2 LABOR ORGANIZATION ANNUAL REPORT
Form Approved
Office of Management and Budget
No.
1245-0003
Expires:
07-31-2019
MUST BE USED BY LABOR ORGANIZATIONS WITH $250,000 OR
MORE IN TOTAL ANNUAL RECEIPTS AND LABOR ORGANIZATIONS IN
TRUSTEESHIP
This report is
mandatory under P.L. 86-257, as amended. Failure to comply
may result in criminal prosecution, fines, or civil penalties as
provided by 29 U.S.C. 439 or 440.
READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS
REPORT.
For Official Use Only
1. FILE NUMBER
025-397
2.
PERIOD COVERED
From
01/01/2016
Through
12/31/2016
3.
(a) AMENDED - Is this an amended report:
No
(b) HARDSHIP - Filed under the hardship procedures:
No
(c) TERMINAL - This
is a terminal report:
No
4. AFFILIATION OR ORGANIZATION NAME
AUTO WORKERS AFL-CIO
5. DESIGNATION (Local, Lodge, etc.)
LOCAL UNION
6. DESIGNATION NBR
376
7. UNIT NAME (if any)
ELMWOOD-HARTFORD LOCAL
8. MAILING ADDRESS (Type or print in capital
letters)
First Name
Michael
Last Name
Langston
P.O Box - Building and Room Number
Number and Street
97 South St.ste 122/124
City
West Hartford
State
CT
ZIP Code + 4
06110
9. Are your organization's records kept at its
mailing address?
Yes
Each of the undersigned, duly authorized
officers of the above labor organization, declares,
under penalty of perjury and other applicable penalties
of law, that all of the information submitted in this
report (including information contained in any
accompanying documents) has been examined by the
signatory and is, to the best of the undersigned
individual's knowledge and belief, true, correct
and complete (See Section V on penalties in the
instructions.)
70. SIGNED:
Craig T Smith
PRESIDENT
71. SIGNED:
Michael A Langston
TREASURER
Date:
Mar 22, 2017
Telephone
Number:
860-953-1346
Date:
Mar 22, 2017
Telephone
Number:
860-953-1346
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
ITEMS 10 THROUGH 21
FILE NUMBER:
025-397
10. During the reporting period did the labor
organization create or participate in the administration of
a trust or a fund or organization, as defined in the
instructions, which provides benefits for members or
beneficiaries?
No
11(a). During the reporting period did the
labor organization have a political action committee (PAC)
fund?
No
11(b). During the reporting period did the
labor organization have a subsidiary organization as
defined in Section X of these Instructions?
No
12. During the reporting period did the labor
organization have an audit or review of its books and
records by an outside accountant or by a parent body
auditor/representative?
No
13. During the reporting period did the labor
organization discover any loss or shortage of funds or
other assets? (Answer "Yes" even if there has
been repayment or recovery.)
No
14. What is the maximum amount recoverable
under the labor organization's fidelity bond for a
loss caused by any officer, employee or agent of the labor
organization who handled union funds?
$100,000
15. During the reporting period did the labor
organization acquire or dispose of any assets in a manner
other than purchase or sale?
No
16. Were any of the labor organization's
assets pledged as security or encumbered in any way at the
end of the reporting period?
No
17. Did the labor organization have any
contingent liabilities at the end of the reporting period?
No
18. During the reporting period did the labor
organization have any changes in its constitution or
bylaws, other than rates of dues and fees, or in
practices/procedures listed in the instructions?
No
19. What is the date of the labor
organization's next regular election of officers?
05/2017
20. How many members did the labor organization
have at the end of the reporting period?
1,602
21. What are the labor organization's rates of dues
and fees?
Rates of Dues and Fees
Dues/Fees
Amount
Unit
Minimum
Maximum
(a) Regular Dues/Fees
2.5 Hours stright time.
per
month
0
0
(b) Working Dues/Fees
per
(c) Initiation Fees
per
(d) Transfer Fees
per
(e) Work Permits
per
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
STATEMENT A - ASSETS
AND LIABILITIES
FILE NUMBER:
025-397
ASSETS
ASSETS
Schedule
Number
Start of Reporting Period
(A)
End of Reporting Period
(B)
22. Cash
$312,016
$392,614
23. Accounts Receivable
1
$0
$0
24. Loans Receivable
2
$0
$0
25. U.S. Treasury
Securities
$0
$0
26. Investments
5
$0
$0
27. Fixed Assets
6
$0
$0
28. Other Assets
7
$2,567
$2,567
29.
TOTAL ASSETS
$314,583
$395,181
LIABILITIES
LIABILITIES
Schedule
Number
Start of Reporting Period
(A)
End of Reporting Period
(B)
30. Accounts Payable
8
$0
$0
31. Loans Payable
9
$0
$0
32. Mortgages Payable
$0
$0
33. Other Liabilities
10
$0
$0
34. TOTAL
LIABILITIES
$0
$0
35. NET
ASSETS
$314,583
$395,181
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
STATEMENT B -
RECEIPTS AND DISBURSEMENTS
FILE NUMBER:
025-397
CASH
RECEIPTS
SCH
AMOUNT
36. Dues and Agency Fees
$963,905
37. Per Capita Tax
$0
38. Fees, Fines,
Assessments, Work Permits
$11,163
39. Sale of Supplies
$0
40. Interest
$0
41. Dividends
$0
42. Rents
$0
43. Sale of Investments
and Fixed Assets
3
$0
44. Loans Obtained
9
$0
45. Repayments of Loans
Made
2
$0
46. On Behalf of
Affiliates for Transmittal to Them
$0
47. From Members for
Disbursement on Their Behalf
$1,320
48. Other Receipts
14
$52,893
49. TOTAL RECEIPTS
$1,029,281
CASH DISBURSEMENTS
SCH
AMOUNT
50.
Representational Activities
15
$311,431
51.
Political Activities and Lobbying
16
$15,637
52.
Contributions, Gifts, and Grants
17
$1,475
53. General
Overhead
18
$6,215
54. Union
Administration
19
$17,422
55. Benefits
20
$41,594
56. Per
Capita Tax
$526,349
57. Strike
Benefits
$0
58. Fees,
Fines, Assessments, etc.
$0
59. Supplies
for Resale
$0
60. Purchase
of Investments and Fixed Assets
4
$0
61. Loans
Made
2
$0
62.
Repayment of Loans Obtained
9
$0
63. To
Affiliates of Funds Collected on Their Behalf
$0
64. On
Behalf of Individual Members
$5,243
65. Direct
Taxes
$15,069
66. Subtotal
$940,435
67.
Withholding Taxes and Payroll Deductions
67a. Total
Withheld
$60,962
67b. Less Total
Disbursed
$69,207
67c.
Total Withheld But Not Disbursed
-$8,245
68.
TOTAL DISBURSEMENTS
$948,680
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 1 - ACCOUNTS
RECEIVABLE AGING SCHEDULE
FILE NUMBER:
025-397
Entity or Individual Name
(A)
Total Account Receivable
(B)
90-180 Days
Past Due
(C)
180+ Days
Past Due
(D)
Liquidated Account
Receivable
(E)
Total of all itemized
accounts receivable
$0
$0
$0
$0
Totals from all other
accounts receivable
Totals
(Total of Column (B) will be automatically entered in Item
23, Column(B))
$0
$0
$0
$0
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 2 - LOANS
RECEIVABLE
FILE NUMBER:
025-397
List below loans to officers, employees, or members which
at any time during the reporting period exceeded $250 and
list all loans to business enterprises regardless of amount.
(A)
Loans
Outstanding at
Start of Period
(B)
Loans Made
During Period
(C)
Repayments Received During Period
Cash
(D)(1)
Other Than Cash
(D)(2)
Loans
Outstanding at
End of Period
(E)
Total of loans not
listed above
Total of all lines
above
$0
$0
$0
$0
$0
Totals will be
automatically entered in...
Item 24
Column (A)
Item 61
Item 45
Item 69
with Explanation
Item 24
Column (B)
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 3 - SALE OF
INVESTMENTS AND FIXED ASSETS
FILE NUMBER:
025-397
Description (if land or buildings, give location)
(A)
Cost
(B)
Book Value
(C)
Gross Sales Price
(D)
Amount Received
(E)
Total of all
lines above
$0
$0
$0
$0
Less Reinvestments
$0
(The
total from Net Sales Line will be automatically entered
in Item 43)
Net Sales
$0
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 4 - PURCHASE
OF INVESTMENTS AND FIXED ASSETS
FILE NUMBER:
025-397
Description (if land or buildings, give location)
(A)
Cost
(B)
Book Value
(C)
Cash Paid
(D)
Total
of all lines above
$0
$0
$0
Less Reinvestments
$0
(The
total from Net Purchases Line will be automatically
entered in Item 60.)
Net Purchases
$0
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 5 -
INVESTMENTS
FILE NUMBER:
025-397
Description
(A)
Amount
(B)
Marketable Securities
A. Total Cost
B. Total Book Value
C. List each
marketable security which has a book value over $5,000
and exceeds 5% of Line B.
Other Investments
D. Total Cost
E. Total Book Value
F. List each other
investment which has a book value over $5,000 and
exceeds 5% of Line E. Also, list each subsidiary
for which separate reports are attached.
G. Total of Lines B and E
(Total will be automatically entered in Item 26,
Column(B))
$0
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 6 - FIXED
ASSETS
FILE NUMBER:
025-397
Description
(A)
Cost or Other Basis
(B)
Total Depreciation or
Amount Expensed
(C)
Book Value
(D)
Value
(E)
A. Land (give
location)
$0
$0
$0
B. Buildings
(give location)
$0
$0
$0
$0
C. Automobiles
and
Other Vehicles
D. Office
Furniture
and Equipment
E.
Other Fixed Assets
F. Totals of Lines A through E
(Column(D) Total will be automatically entered in Item
27, Column(B))
$0
$0
$0
$0
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 7 - OTHER
ASSETS
FILE NUMBER:
025-397
Description
(A)
Book Value
(B)
Total
(Total will be automatically entered in Item 28, Column(B))
$2,567
Lease deposit
$2,567
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 8 - ACCOUNTS
PAYABLE AGING SCHEDULE
FILE NUMBER:
025-397
Entity or Individual Name
(A)
Total Account
Payable
(B)
90-180 Days
Past Due
(C)
180+ Days Past
Due
(D)
Liquidated Account
Payable
(E)
Total for all itemized accounts payable
$0
$0
$0
$0
Total from all other accounts payable
$0
$0
$0
$0
Totals
(Total for Column(B) will be automatically entered in Item
30, Column(D))
$0
$0
$0
$0
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 9 - LOANS
PAYABLE
FILE NUMBER:
025-397
Source of Loans Payable at Any
Time During the Reporting Period
(A)
Loans Owed at
Start of Period
(B)
Loans Obtained
During Period
(C)
Repayment
During Period
Cash
(D)(1)
Repayment
During Period
Other Than Cash
(D)(2)
Loans Owed at
End of Period
(E)
Total Loans Payable
$0
$0
$0
$0
$0
Totals will be automatically entered in...
Item 31
Column (C)
Item 44
Item 62
Item 69
with Explanation
Item 31
Column (D)
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 10 - OTHER
LIABILITIES
FILE NUMBER:
025-397
Description
(A)
Amount at End of Period
(B)
Total Other Liabilities
(Total will be automatically entered in Item 33, Column(D))
$0
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 11 - ALL
OFFICERS AND DISBURSEMENTS TO OFFICERS
FILE NUMBER:
025-397
(A) Name
(B) Title
(C) Status
(D)
Gross Salary
Disbursements
(before any
deductions)
(E)
Allowances
Disbursed
(F)
Disbursements
for Official Business
(G)
Other
Disbursements not reported in
(D) through (F)
(H)
TOTAL
A
B
C
Brown
,
Dennis
Vice President C
$5,905
$0
$1,167
$0
$7,072
I
Schedule 15
Representational Activities
88
%
Schedule 16
Political Activities and Lobbying
12
%
Schedule 17
Contributions
0
%
Schedule 18
General Overhead
0
%
Schedule 19
Administration
0
%
A
B
C
Demkow
,
Peter
Trustee C
$1,070
$0
$230
$0
$1,300
I
Schedule 15
Representational Activities
100
%
Schedule 16
Political Activities and Lobbying
0
%
Schedule 17
Contributions
0
%
Schedule 18
General Overhead
0
%
Schedule 19
Administration
0
%
A
B
C
Garcia
,
Marilyn
Recording Secretary C
$1,433
$0
$230
$0
$1,663
I
Schedule 15
Representational Activities
93
%
Schedule 16
Political Activities and Lobbying
7
%
Schedule 17
Contributions
0
%
Schedule 18
General Overhead
0
%
Schedule 19
Administration
0
%
A
B
C
Green
,
Henriet
Trustee C
$0
$0
$0
$0
$0
I
Schedule 15
Representational Activities
100
%
Schedule 16
Political Activities and Lobbying
0
%
Schedule 17
Contributions
0
%
Schedule 18
General Overhead
0
%
Schedule 19
Administration
0
%
A
B
C
Kaplenski
,
Peter
Trustee C
$0
$0
$230
$0
$230
I
Schedule 15
Representational Activities
100
%
Schedule 16
Political Activities and Lobbying
0
%
Schedule 17
Contributions
0
%
Schedule 18
General Overhead
0
%
Schedule 19
Administration
0
%
A
B
C
Langston
,
Michael
FINANCIAL SECRETARY C
$42,300
$3,835
$11,989
$0
$58,124
I
Schedule 15
Representational Activities
92
%
Schedule 16
Political Activities and Lobbying
2
%
Schedule 17
Contributions
0
%
Schedule 18
General Overhead
0
%
Schedule 19
Administration
6
%
A
B
C
Rivera
,
Jose
Trustee C
$0
$0
$0
$0
$0
I
Schedule 15
Representational Activities
100
%
Schedule 16
Political Activities and Lobbying
0
%
Schedule 17
Contributions
0
%
Schedule 18
General Overhead
0
%
Schedule 19
Administration
0
%
A
B
C
Smith
,
Craig
President C
$91,119
$7,670
$1,903
$0
$100,692
I
Schedule 15
Representational Activities
89
%
Schedule 16
Political Activities and Lobbying
6
%
Schedule 17
Contributions
0
%
Schedule 18
General Overhead
0
%
Schedule 19
Administration
5
%
A
B
C
Storey
,
Jacquel
Guide C
$0
$0
$0
$0
$0
I
Schedule 15
Representational Activities
100
%
Schedule 16
Political Activities and Lobbying
0
%
Schedule 17
Contributions
0
%
Schedule 18
General Overhead
0
%
Schedule 19
Administration
0
%
Total Officer
Disbursements
$141,827
$11,505
$15,749
$0
$169,081
Less Deductions
$47,688
Net
Disbursements
$121,393
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 12 -
DISBURSEMENTS TO EMPLOYEES
FILE NUMBER:
025-397
(A) Name
(B) Title
(C) Other Payer
(D)
Gross Salary
Disbursements
(before any
deductions)
(E)
Allowances Disbursed
(F)
Disbursements for Official Business
(G)
Other Disbursements not reported in
(D) through (F)
(H)
TOTAL
A
B
C
Levesque
,
Patrici
NA NA
$22,133
$0
$0
$0
$22,133
I
Schedule 15
Representational Activities
76
%
Schedule 16
Political Activities and Lobbying
0
%
Schedule 17
Contributions
0
%
Schedule 18
General Overhead
0
%
Schedule 19
Administration
24
%
TOTALS RECEIVED
BY EMPLOYEES MAKING $10,000 OR LESS
$18,244
$0
$3,113
$0
$21,357
I
Schedule 15
Representational Activities
81
%
Schedule 16
Political Activities and Lobbying
14
%
Schedule 17
Contributions
0
%
Schedule 18
General Overhead
0
%
Schedule 19
Administration
5
%
Total
Employee Disbursements
$40,377
$0
$3,113
$0
$43,490
Less
Deductions
$13,273
Net Disbursements
$30,217
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 13 -
MEMBERSHIP STATUS
FILE NUMBER:
025-397
Category of Membership
(A)
Number
(B)
Voting Eligibility
(C)
Members
(Total of all lines above)
1,602
Agency Fee Payers*
0
Total Members/Fee Payers
1,602
*Agency Fee Payers are
not considered members of the labor organization.
Regular members
1,602
Yes
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
DETAILED SUMMARY PAGE
- SCHEDULES 14 THROUGH 19
FILE NUMBER:
025-397
SCHEDULE 14 OTHER RECEIPTS
1. Named Payer
Itemized Receipts
$50,808
2. Named Payer
Non-itemized Receipts
$400
3. All Other Receipts
$1,685
4. Total
Receipts
$52,893
SCHEDULE 17 CONTRIBUTIONS,
GIFTS & GRANTS
1. Named Payee
Itemized Disbursements
$0
2. Named Payee
Non-itemized Disbursements
$0
3. To Officers
$0
4. To Employees
$0
5. All Other
Disbursements
$1,475
6. Total
Disbursements
$1,475
SCHEDULE 15 REPRESENTATIONAL
ACTIVITIES
1. Named Payee
Itemized Disbursements
$11,709
2. Named Payee
Non-itemized Disbursements
$34,774
3. To Officers
$152,390
4. To Employees
$34,120
5. All Other
Disbursements
$78,438
6. Total
Disbursements
$311,431
SCHEDULE 18 GENERAL OVERHEAD
1. Named Payee
Itemized Disbursements
$0
2. Named Payee
Non-itemized Disbursements
$0
3. To Officers
$0
4. To Employees
$0
5. All Other
Disbursements
$6,215
6. Total
Disbursements
$6,215
SCHEDULE 16 POLITICAL
ACTIVITIES AND LOBBYING
1. Named Payee
Itemized Disbursements
$0
2. Named Payee
Non-itemized Disbursements
$0
3. To Officers
$8,169
4. To Employees
$2,990
5. All Other
Disbursements
$4,478
6. Total
Disbursements
$15,637
SCHEDULE 19 UNION
ADMINISTRATION
1. Named Payee
Itemized Disbursements
$0
2. Named Payee
Non-itemized Disbursements
$0
3. To Officers
$8,522
4. To Employees
$6,380
5. All Other
Disbursements
$2,520
6. Total
Disbursements
$17,422
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 14 - OTHER
RECEIPTS
FILE NUMBER:
025-397
Name and Address
(A)
Bruno Necatera 80 Harvard Ave
Stamford CT 06902-0000
Type or Classification
(B)
taxi service
Purpose
(C)
Date
(D)
Amount
(E)
Total
Itemized Transactions with this Payee/Payer
$30,000
Total
Non-Itemized Transactions with this Payee/Payer
$0
Total of All Transactions with this
Payee/Payer for This Schedule
$30,000
Stamford Taxi arb. settle
03/30/2016
$30,000
Name and Address
(A)
International Union UAW 8000 E. Jefferson Ave.
Detroit MI 48214-0000
Type or Classification
(B)
Labor Organization
Purpose
(C)
Date
(D)
Amount
(E)
Total
Itemized Transactions with this Payee/Payer
$20,808
Total
Non-Itemized Transactions with this Payee/Payer
$400
Total of All Transactions with this
Payee/Payer for This Schedule
$21,208
per capita rebate
04/22/2016
$13,361
servicing sub
03/29/2016
$7,447
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 15 -
REPRESENTATIONAL ACTIVITIES
FILE NUMBER:
025-397
Name and Address
(A)
101 South LLC PO Box 747
Farmington CT 06034-0747
Type or Classification
(B)
landlord
Purpose
(C)
Date
(D)
Amount
(E)
Total
Itemized Transactions with this Payee/Payer
$0
Total
Non-Itemized Transactions with this Payee/Payer
$21,834
Total of All Transactions with this
Payee/Payer for This Schedule
$21,834
Name and Address
(A)
Cape Codder Resort & Spa 1225 Iyannough Road
Hyannis MA 02601-0000
Type or Classification
(B)
hotel
Purpose
(C)
Date
(D)
Amount
(E)
Total
Itemized Transactions with this Payee/Payer
$11,709
Total
Non-Itemized Transactions with this Payee/Payer
$0
Total of All Transactions with this
Payee/Payer for This Schedule
$11,709
Leadership conf.
08/17/2016
$11,709
Name and Address
(A)
D.L. Peterson Trust 5924 Collections Center D
Chicago IL 60693-0000
Type or Classification
(B)
gasoline
Purpose
(C)
Date
(D)
Amount
(E)
Total
Itemized Transactions with this Payee/Payer
Total
Non-Itemized Transactions with this Payee/Payer
$5,617
Total of All Transactions with this
Payee/Payer for This Schedule
$5,617
Name and Address
(A)
LIVINGSTON ADLER PUDLER MEI 555 PROSPECT AVE
HARTFORD CT 06105-0000
Type or Classification
(B)
LEGAL
Purpose
(C)
Date
(D)
Amount
(E)
Total
Itemized Transactions with this Payee/Payer
$0
Total
Non-Itemized Transactions with this Payee/Payer
$7,323
Total of All Transactions with this
Payee/Payer for This Schedule
$7,323
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 16 -
POLITICAL ACTIVITIES AND LOBBYING
FILE NUMBER
025-397
Name and Address
(A)
-1
Type or Classification
(B)
Purpose
(C)
Date
(D)
Amount
(E)
Total
Itemized Transactions with this Payee/Payer
Total
Non-Itemized Transactions with this Payee/Payer
Total of All Transactions with this
Payee/Payer for This Schedule
$0
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 17 -
CONTRIBUTIONS, GIFTS & GRANTS
FILE NUMBER:
025-397
Name and Address
(A)
-1
Type or Classification
(B)
Purpose
(C)
Date
(D)
Amount
(E)
Total
Itemized Transactions with this Payee/Payer
Total
Non-Itemized Transactions with this Payee/Payer
Total of All Transactions with this
Payee/Payer for This Schedule
$0
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 18 - GENERAL
OVERHEAD
FILE NUMBER:
025-397
Name and Address
(A)
-1
Type or Classification
(B)
Purpose
(C)
Date
(D)
Amount
(E)
Total
Itemized Transactions with this Payee/Payer
Total
Non-Itemized Transactions with this Payee/Payer
Total of All Transactions with this
Payee/Payer for This Schedule
$0
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 19 - UNION
ADMINISTRATION
FILE NUMBER:
025-397
Name and Address
(A)
-1
Type or Classification
(B)
Purpose
(C)
Date
(D)
Amount
(E)
Total
Itemized Transactions with this Payee/Payer
Total
Non-Itemized Transactions with this Payee/Payer
Total of All Transactions with this
Payee/Payer for This Schedule
$0
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
SCHEDULE 20 -
BENEFITS
FILE NUMBER:
025-397
Description
(A)
To Whom Paid
(B)
Amount
(C)
Total of all
lines above (Total will be automatically entered in Item
55.)
$41,594
Dental/Hearing/Medical/Vision Insurance
AMWINS Group Benefits
$1,036
Dental/Hearing/Medical/Vision Insurance
Anthem Blue Cross/Blue Shield
$35,326
Group Life Insurance
AMWINS Group Benefits
$539
Group Life Insurance
The Hartford
$286
Workers Compension Insurance
Peerless Insurance
$2,858
Medical Fees- To Doc/Hosp as a Co-Pay
Middlesex Hospital
$1,349
Medical Fees- To Doc/Hosp as a Co-Pay
Yale New Haven Health System
$200
Form LM-2 (Revised 2010); (Tech. Rev. 2/2013)
69. ADDITIONAL
INFORMATION SUMMARY
FILE NUMBER:
025-397
Schedule 13, Row1:
Schedule 13, Row1::
Schedule 13, Row1:
Schedule 13, Row1::Anyone who applies for and is accepted for membership is a regular member. Regular members pay full dues