401k Plan data: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN plan

DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 401k Plan overview

Plan Name	DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN
Plan identification number	001

DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. has sponsored the creation of one or more 401k plans.

Company Name: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.

Employer identification number (EIN): 431747760

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01
001 2021-03-01
001 2020-02-29
001 2019-03-01 TIM SHRYACK 2020-09-23
001 2018-03-01 TIM SHRYACK 2019-12-17
001 2017-03-01 TIM SHRYACK 2018-09-27
001 2016-03-01 TIM SHRYACK 2017-08-24
001 2015-03-01 TIM SHRYACK 2016-07-05
001 2014-03-01 TIM SHRYACK 2015-06-23
001 2013-03-01 TIM SHRYACK 2014-05-30
001 2012-03-01 TIM SHRYACK 2013-09-17
001 2011-03-01 RICHARD SIMS 2012-10-10
001 2010-03-01 RICHARD SIMS 2011-12-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2022-01-01
001	2021-03-01
001	2020-02-29
001	2019-03-01	TIM SHRYACK	2020-09-23
001	2018-03-01	TIM SHRYACK	2019-12-17
001	2017-03-01	TIM SHRYACK	2018-09-27
001	2016-03-01	TIM SHRYACK	2017-08-24
001	2015-03-01	TIM SHRYACK	2016-07-05
001	2014-03-01	TIM SHRYACK	2015-06-23
001	2013-03-01	TIM SHRYACK	2014-05-30
001	2012-03-01	TIM SHRYACK	2013-09-17
001	2011-03-01	RICHARD SIMS	2012-10-10
001	2010-03-01	RICHARD SIMS	2011-12-13

Plan Statistics for DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN

401k plan membership statisitcs for DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN

Measure Date Value
2022: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 141
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 99
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 99
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 99
Number of participants with account balances 2022-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-03-01 128
Total number of active participants reported on line 7a of the Form 5500 2021-03-01 93
Number of retired or separated participants receiving benefits 2021-03-01 6
Number of other retired or separated participants entitled to future benefits 2021-03-01 42
Total of all active and inactive participants 2021-03-01 141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-03-01 0
Total participants 2021-03-01 141
Number of participants with account balances 2021-03-01 141
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-03-01 0
2020: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-02-29 122
Total number of active participants reported on line 7a of the Form 5500 2020-02-29 97
Number of retired or separated participants receiving benefits 2020-02-29 4
Number of other retired or separated participants entitled to future benefits 2020-02-29 27
Total of all active and inactive participants 2020-02-29 128
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-02-29 0
Total participants 2020-02-29 128
Number of participants with account balances 2020-02-29 128
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-02-29 0

Measure	Date	Value
2022: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	99
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	99
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	99
Number of participants with account balances	2022-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-03-01	128
Total number of active participants reported on line 7a of the Form 5500	2021-03-01	93
Number of retired or separated participants receiving benefits	2021-03-01	6
Number of other retired or separated participants entitled to future benefits	2021-03-01	42
Total of all active and inactive participants	2021-03-01	141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-03-01	0
Total participants	2021-03-01	141
Number of participants with account balances	2021-03-01	141
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-03-01	0
2020: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-02-29	122
Total number of active participants reported on line 7a of the Form 5500	2020-02-29	97
Number of retired or separated participants receiving benefits	2020-02-29	4
Number of other retired or separated participants entitled to future benefits	2020-02-29	27
Total of all active and inactive participants	2020-02-29	128
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-02-29	0
Total participants	2020-02-29	128
Number of participants with account balances	2020-02-29	128
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-02-29	0

Financial Data on DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN

Measure	Date	Value
2022 : DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 2022 401k financial data
Total income from all sources (including contributions)	2022-12-31	$92,878
Total of all expenses incurred	2022-12-31	$183,180
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$162,637
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$590,175
Value of total assets at end of year	2022-12-31	$3,144,497
Value of total assets at beginning of year	2022-12-31	$3,234,799
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$20,543
Total interest from all sources	2022-12-31	$4,957
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Administrative expenses professional fees incurred	2022-12-31	$3,026
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$3,243,480
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$354,265
Participant contributions at end of year	2022-12-31	$68,330
Participant contributions at beginning of year	2022-12-31	$100,918
Participant contributions at end of year	2022-12-31	$8,613
Participant contributions at beginning of year	2022-12-31	$11,433
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$23,163
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-90,302
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$3,144,497
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$3,234,799
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in pooled separate accounts at end of year	2022-12-31	$2,825,805
Value of interest in pooled separate accounts at beginning of year	2022-12-31	$2,939,669
Interest on participant loans	2022-12-31	$4,576
Interest earned on other investments	2022-12-31	$381
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$29,002
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$14,427
Net investment gain/loss from pooled separate accounts	2022-12-31	$-502,254
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$212,747
Employer contributions (assets) at end of year	2022-12-31	$212,747
Employer contributions (assets) at beginning of year	2022-12-31	$168,352
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$162,637
Contract administrator fees	2022-12-31	$17,517
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2022-12-31	No
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	THE WHITLOCK CO. LLP
Accountancy firm EIN	2022-12-31	431365401
2021 : DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$739,895
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$126,268
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$108,507
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$458,911
Value of total assets at end of year	2021-12-31	$3,234,799
Value of total assets at beginning of year	2021-12-31	$2,621,172
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$17,761
Total interest from all sources	2021-12-31	$5,386
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Administrative expenses professional fees incurred	2021-12-31	$750
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$262,118
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$249,509
Participant contributions at end of year	2021-12-31	$100,918
Participant contributions at beginning of year	2021-12-31	$131,341
Participant contributions at end of year	2021-12-31	$11,433
Participant contributions at beginning of year	2021-12-31	$11,423
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$41,050
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$613,627
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$3,234,799
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$2,621,172
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in pooled separate accounts at end of year	2021-12-31	$2,939,669
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$2,291,033
Interest on participant loans	2021-12-31	$5,263
Interest earned on other investments	2021-12-31	$123
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$14,427
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$7,645
Net investment gain/loss from pooled separate accounts	2021-12-31	$275,598
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$168,352
Employer contributions (assets) at end of year	2021-12-31	$168,352
Employer contributions (assets) at beginning of year	2021-12-31	$179,730
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$108,507
Contract administrator fees	2021-12-31	$17,011
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	THE WHITLOCK CO. LLP
Accountancy firm EIN	2021-12-31	431365401
Total unrealized appreciation/depreciation of assets	2021-02-28	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-02-28	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-02-28	$0
Total income from all sources (including contributions)	2021-02-28	$1,097,008
Total loss/gain on sale of assets	2021-02-28	$0
Total of all expenses incurred	2021-02-28	$478,332
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-02-28	$459,915
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-02-28	$647,284
Value of total assets at end of year	2021-02-28	$2,621,172
Value of total assets at beginning of year	2021-02-28	$2,002,496
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-02-28	$18,417
Total interest from all sources	2021-02-28	$6,896
Total dividends received (eg from common stock, registered investment company shares)	2021-02-28	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-02-28	No
Was this plan covered by a fidelity bond	2021-02-28	Yes
Value of fidelity bond cover	2021-02-28	$200,250
If this is an individual account plan, was there a blackout period	2021-02-28	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-02-28	$0
Were there any nonexempt tranactions with any party-in-interest	2021-02-28	No
Contributions received from participants	2021-02-28	$255,301
Participant contributions at end of year	2021-02-28	$131,341
Participant contributions at beginning of year	2021-02-28	$51,755
Participant contributions at end of year	2021-02-28	$11,423
Participant contributions at beginning of year	2021-02-28	$9,577
Income. Received or receivable in cash from other sources (including rollovers)	2021-02-28	$212,253
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-02-28	No
Value of net income/loss	2021-02-28	$618,676
Value of net assets at end of year (total assets less liabilities)	2021-02-28	$2,621,172
Value of net assets at beginning of year (total assets less liabilities)	2021-02-28	$2,002,496
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-02-28	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-02-28	No
Were any leases to which the plan was party in default or uncollectible	2021-02-28	No
Investment advisory and management fees	2021-02-28	$16,842
Value of interest in pooled separate accounts at end of year	2021-02-28	$2,291,033
Value of interest in pooled separate accounts at beginning of year	2021-02-28	$1,779,821
Interest on participant loans	2021-02-28	$6,203
Interest earned on other investments	2021-02-28	$693
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-02-28	$7,645
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-02-28	$0
Net investment gain/loss from pooled separate accounts	2021-02-28	$442,828
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-02-28	Yes
Was there a failure to transmit to the plan any participant contributions	2021-02-28	No
Has the plan failed to provide any benefit when due under the plan	2021-02-28	No
Contributions received in cash from employer	2021-02-28	$179,730
Employer contributions (assets) at end of year	2021-02-28	$179,730
Employer contributions (assets) at beginning of year	2021-02-28	$161,343
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-02-28	$459,915
Contract administrator fees	2021-02-28	$1,575
Did the plan have assets held for investment	2021-02-28	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-02-28	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-02-28	No
Opinion of an independent qualified public accountant for this plan	2021-02-28	Unqualified
Accountancy firm name	2021-02-28	THE WHITLOCK CO. LLP
Accountancy firm EIN	2021-02-28	431365401

Form 5500 Responses for DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN

2022: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 2021 form 5500 responses
2021-03-01	Type of plan entity	Single employer plan
2021-03-01	Submission has been amended	No
2021-03-01	This submission is the final filing	No
2021-03-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2021-03-01	Plan is a collectively bargained plan	No
2021-03-01	Plan funding arrangement – Insurance	Yes
2021-03-01	Plan funding arrangement – Trust	Yes
2021-03-01	Plan benefit arrangement – Insurance	Yes
2021-03-01	Plan benefit arrangement - Trust	Yes
2020: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. 401K RETIREMENT PLAN 2020 form 5500 responses
2020-02-29	Type of plan entity	Single employer plan
2020-02-29	Submission has been amended	No
2020-02-29	This submission is the final filing	No
2020-02-29	This return/report is a short plan year return/report (less than 12 months)	No
2020-02-29	Plan is a collectively bargained plan	No
2020-02-29	Plan funding arrangement – Insurance	Yes
2020-02-29	Plan funding arrangement – Trust	Yes
2020-02-29	Plan benefit arrangement – Insurance	Yes
2020-02-29	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

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

Policy contract number

GP361AA/HIJ8

Policy instance

Insurance contract or identification number	GP361AA/HIJ8
Number of Individuals Covered	133
Total amount of commissions paid to insurance broker	USD $8,371
Total amount of fees paid to insurance company	USD $1,396
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Commission paid to Insurance Broker	USD $8,371
Insurance broker organization code?	4
Amount paid for insurance broker fees	1396

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

Policy contract number

GP361AA/H1J8

Policy instance

Insurance contract or identification number	GP361AA/H1J8
Number of Individuals Covered	131
Insurance policy start date	2021-03-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,397
Total amount of fees paid to insurance company	USD $1,267
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?	Yes
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	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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,575
Insurance broker organization code?	4
Amount paid for insurance broker fees	1267
Additional information about fees paid to insurance broker	FEES

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

Policy contract number

GP361AA/H1J8

Policy instance

Insurance contract or identification number	GP361AA/H1J8
Number of Individuals Covered	104
Insurance policy start date	2020-02-29
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $8,599
Total amount of fees paid to insurance company	USD $1,063
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?	Yes
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	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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,741
Insurance broker organization code?	4
Amount paid for insurance broker fees	1063
Additional information about fees paid to insurance broker	FEES

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Company Name:	DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Employer identification number (EIN):	431747760
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)