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| Plan Name | HEALTH INSURANCE |
| Plan identification number | 601 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | AMERICAN DISH SERVICE |
| Employer identification number (EIN): | 431031331 |
| NAIC Classification: | 333310 |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 601 | 2019-01-01 | ||||
| 601 | 2018-01-01 | MICHELLE HATFIELD | |||
| 601 | 2018-01-01 | ||||
| 601 | 2017-01-01 | MICHELLE HATFIELD |
| Measure | Date | Value |
|---|---|---|
| 2019: HEALTH INSURANCE 2019 401k membership | ||
| Total participants, beginning-of-year | 2019-01-01 | 107 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 104 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 104 |
| Total participants | 2019-01-01 | 104 |
| 2018: HEALTH INSURANCE 2018 401k membership | ||
| Total participants, beginning-of-year | 2018-01-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 100 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 100 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2018-01-01 | 0 |
| Total participants | 2018-01-01 | 100 |
| 2017: HEALTH INSURANCE 2017 401k membership | ||
| Total participants, beginning-of-year | 2017-01-01 | 90 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 106 |
| Total of all active and inactive participants | 2017-01-01 | 106 |
| Total participants | 2017-01-01 | 106 |
| 2019: HEALTH INSURANCE 2019 form 5500 responses | ||
|---|---|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: HEALTH INSURANCE 2018 form 5500 responses | ||
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | Yes |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: HEALTH INSURANCE 2017 form 5500 responses | ||
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | First time form 5500 has been submitted | Yes |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 0109557 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 34673000 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 34673000 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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