401k Plan data: NORTH COUNTRY HOSPITAL FLEXIBLE BENEFITS PLAN plan

NORTH COUNTRY HOSPITAL FLEXIBLE BENEFITS PLAN 401k Plan overview

Plan Name	NORTH COUNTRY HOSPITAL FLEXIBLE BENEFITS PLAN
Plan identification number	501

NORTH COUNTRY HOSPITAL FLEXIBLE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	SELECT distinct(Description) AS Description FROM 401k_benefit_codes LEFT JOIN 401k_benefit_code_description ON BenefitCode=Code COLLATE utf8_unicode_ci WHERE EIN='030185556' AND PlanID='501'

401k Sponsoring company profile

NORTH COUNTRY HEALTH SYSTEM, INC. has sponsored the creation of one or more 401k plans.

Company Name: NORTH COUNTRY HEALTH SYSTEM, INC.

Employer identification number (EIN): 030185556

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NORTH COUNTRY HOSPITAL FLEXIBLE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2024-01-01 FRED SCHAFFNER
501 2023-01-01
501 2023-01-01 FRED SCHAFFNER
501 2022-01-01
501 2022-01-01 TRACEY PAUL
501 2021-01-01
501 2021-01-01
501 2021-01-01 PAUL GIORDANO
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 WILLIAM PERKET WILLIAM PERKET 2018-07-24
501 2016-01-01 WILLIAM PERKET WILLIAM PERKET 2017-07-10
501 2015-01-01 WILLIAM PERKET WILLIAM PERKET 2016-06-24
501 2014-01-01 WILLIAM PERKET WILLIAM PERKET 2015-06-23
501 2013-01-01 WILLIAM PERKET WILLIAM PERKET 2014-07-22
501 2012-01-01 WILLIAM PERKET WILLIAM PERKET 2013-07-19
501 2011-01-01 WILLIAM PERKET WILLIAM PERKET 2012-07-26
501 2010-01-01 WILLIAM PERKET WILLIAM PERKET 2011-07-20
501 2009-01-01 WILLIAM PERKET WILLIAM PERKET 2011-05-23
501 2009-01-01 WILLIAM PERKET WILLIAM PERKET 2010-09-09

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2024-01-01	FRED SCHAFFNER
501	2023-01-01
501	2023-01-01	FRED SCHAFFNER
501	2022-01-01
501	2022-01-01	TRACEY PAUL
501	2021-01-01
501	2021-01-01
501	2021-01-01	PAUL GIORDANO
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	WILLIAM PERKET	WILLIAM PERKET	2018-07-24
501	2016-01-01	WILLIAM PERKET	WILLIAM PERKET	2017-07-10
501	2015-01-01	WILLIAM PERKET	WILLIAM PERKET	2016-06-24
501	2014-01-01	WILLIAM PERKET	WILLIAM PERKET	2015-06-23
501	2013-01-01	WILLIAM PERKET	WILLIAM PERKET	2014-07-22
501	2012-01-01	WILLIAM PERKET	WILLIAM PERKET	2013-07-19
501	2011-01-01	WILLIAM PERKET	WILLIAM PERKET	2012-07-26
501	2010-01-01	WILLIAM PERKET	WILLIAM PERKET	2011-07-20
501	2009-01-01	WILLIAM PERKET	WILLIAM PERKET	2011-05-23
501	2009-01-01	WILLIAM PERKET	WILLIAM PERKET	2010-09-09

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3337496

Policy instance

Insurance contract or identification number	3337496
Number of Individuals Covered	747
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $26,419
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $577,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

71008

Policy instance

Insurance contract or identification number	71008
Number of Individuals Covered	459
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $10,536
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $235,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

69893-8

Policy instance

Insurance contract or identification number	69893-8
Number of Individuals Covered	486
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,240
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $80,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30062909

Policy instance

Insurance contract or identification number	30062909
Number of Individuals Covered	323
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,304
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $74,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30062909

Policy instance

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

69893-8

Policy instance

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

71008

Policy instance

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3337496

Policy instance

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

GF3810B6360401

Policy instance

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

PD3810B6360401

Policy instance

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

69893-8

Policy instance

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30062909

Policy instance

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30062909

Policy instance

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3337496

Policy instance

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30062909

Policy instance

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3337496

Policy instance

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30062909

Policy instance

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3337496

Policy instance

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30062909

Policy instance

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3337496

Policy instance

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3337496

Policy instance

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9708892

Policy instance

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3337496

Policy instance

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9708892

Policy instance

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

Policy instance

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9708892

Policy instance

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9708892

Policy instance

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

Policy instance

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9708892

Policy instance

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

Policy instance

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

Policy instance

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9708892

Policy instance

Potentially related plans

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Company Name:	NORTH COUNTRY HEALTH SYSTEM, INC.
Employer identification number (EIN):	030185556
NAIC Classification:	622000
NAIC Description:	Hospitals