401k Plan data: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN plan

AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 401k Plan overview

Plan Name	AMERICAN HOSPICE MANAGEMENT 401(K) PLAN
Plan identification number	001

AMERICAN HOSPICE MANAGEMENT 401(K) 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

AMERICAN HOSPICE MANAGEMENT has sponsored the creation of one or more 401k plans.

Company Name: AMERICAN HOSPICE MANAGEMENT

Employer identification number (EIN): 593154237

NAIC Classification: 621399
NAIC Description: Offices of All Other Miscellaneous Health Practitioners

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMERICAN HOSPICE MANAGEMENT 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2015-01-01
001 2015-01-01
001 2014-01-01
001 2013-01-01
001 2012-01-01 JEFFREY PREUSS
001 2011-01-01 JEFFREY PREUSS
001 2010-01-01 SANDY ALBERT
001 2009-01-01 ROBERT A. MCKENDRY
001 2009-01-01 2010-10-14

Plan Statistics for AMERICAN HOSPICE MANAGEMENT 401(K) PLAN

401k plan membership statisitcs for AMERICAN HOSPICE MANAGEMENT 401(K) PLAN

Measure Date Value
2015: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 854
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 378
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 161
Total of all active and inactive participants 2015-01-01 539
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 539
Number of participants with account balances 2015-01-01 284
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 20
2014: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,027
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 640
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 181
Total of all active and inactive participants 2014-01-01 821
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 821
Number of participants with account balances 2014-01-01 407
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 22
2013: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,141
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 873
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 156
Total of all active and inactive participants 2013-01-01 1,029
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 1,029
Number of participants with account balances 2013-01-01 460
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 29
2012: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,121
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 943
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 286
Total of all active and inactive participants 2012-01-01 1,229
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 1,229
Number of participants with account balances 2012-01-01 448
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,076
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 922
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 111
Total of all active and inactive participants 2011-01-01 1,033
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 1,033
Number of participants with account balances 2011-01-01 452
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 29
2010: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 909
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 773
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 273
Total of all active and inactive participants 2010-01-01 1,046
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 1,046
Number of participants with account balances 2010-01-01 406
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 1,024
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 840
Number of retired or separated participants receiving benefits 2009-01-01 1
Number of other retired or separated participants entitled to future benefits 2009-01-01 68
Total of all active and inactive participants 2009-01-01 909
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 909
Number of participants with account balances 2009-01-01 338
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 16

Measure	Date	Value
2015: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	854
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	378
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	161
Total of all active and inactive participants	2015-01-01	539
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	539
Number of participants with account balances	2015-01-01	284
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	20
2014: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,027
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	640
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	181
Total of all active and inactive participants	2014-01-01	821
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	821
Number of participants with account balances	2014-01-01	407
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	22
2013: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,141
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	873
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	156
Total of all active and inactive participants	2013-01-01	1,029
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	1,029
Number of participants with account balances	2013-01-01	460
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	29
2012: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,121
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	943
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	286
Total of all active and inactive participants	2012-01-01	1,229
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	1,229
Number of participants with account balances	2012-01-01	448
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,076
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	922
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	111
Total of all active and inactive participants	2011-01-01	1,033
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	1,033
Number of participants with account balances	2011-01-01	452
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	29
2010: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	909
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	773
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	273
Total of all active and inactive participants	2010-01-01	1,046
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	1,046
Number of participants with account balances	2010-01-01	406
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	1,024
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	840
Number of retired or separated participants receiving benefits	2009-01-01	1
Number of other retired or separated participants entitled to future benefits	2009-01-01	68
Total of all active and inactive participants	2009-01-01	909
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	909
Number of participants with account balances	2009-01-01	338
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	16

Financial Data on AMERICAN HOSPICE MANAGEMENT 401(K) PLAN

Measure	Date	Value
2015 : AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2015 401k financial data
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total income from all sources (including contributions)	2015-12-31	$507,544
Total of all expenses incurred	2015-12-31	$2,371,442
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$2,329,251
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$637,229
Value of total assets at end of year	2015-12-31	$7,167,398
Value of total assets at beginning of year	2015-12-31	$9,031,296
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$42,191
Total interest from all sources	2015-12-31	$528
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Administrative expenses professional fees incurred	2015-12-31	$42,191
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$500,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$634,623
Income. Received or receivable in cash from other sources (including rollovers)	2015-12-31	$957
Total non interest bearing cash at end of year	2015-12-31	$23,221
Total non interest bearing cash at beginning of year	2015-12-31	$22,576
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$-1,863,898
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$7,167,398
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$9,031,296
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2015-12-31	$7,109,316
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$8,970,798
Interest earned on other investments	2015-12-31	$528
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-12-31	$34,861
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$37,922
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$-130,213
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	No
Was there a failure to transmit to the plan any participant contributions	2015-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$1,649
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$2,329,251
Did the plan have assets held for investment	2015-12-31	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	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	DIXON HUGHES GOODMAN LLP
Accountancy firm EIN	2015-12-31	560747981
2014 : AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total income from all sources (including contributions)	2014-12-31	$1,279,798
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$2,022,771
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$2,013,652
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$911,404
Value of total assets at end of year	2014-12-31	$9,031,296
Value of total assets at beginning of year	2014-12-31	$9,774,269
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$9,119
Total interest from all sources	2014-12-31	$750
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Administrative expenses professional fees incurred	2014-12-31	$9,119
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$500,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$907,057
Income. Received or receivable in cash from other sources (including rollovers)	2014-12-31	$4,347
Other income not declared elsewhere	2014-12-31	$910
Administrative expenses (other) incurred	2014-12-31	$0
Total non interest bearing cash at end of year	2014-12-31	$22,576
Total non interest bearing cash at beginning of year	2014-12-31	$7,914
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$-742,973
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$9,031,296
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$9,774,269
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2014-12-31	$8,970,798
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2014-12-31	$9,705,210
Interest earned on other investments	2014-12-31	$750
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$37,922
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$61,145
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$366,734
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	No
Was there a failure to transmit to the plan any participant contributions	2014-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$2,013,652
Did the plan have assets held for investment	2014-12-31	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	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	DIXON HUGHES GOODMAN LLP
Accountancy firm EIN	2014-12-31	560747981
2013 : AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2013 401k financial data
Total unrealized appreciation/depreciation of assets	2013-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total income from all sources (including contributions)	2013-12-31	$2,881,067
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$1,256,917
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$1,250,335
Value of total corrective distributions	2013-12-31	$570
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$1,494,110
Value of total assets at end of year	2013-12-31	$9,774,269
Value of total assets at beginning of year	2013-12-31	$8,150,119
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$6,012
Total interest from all sources	2013-12-31	$1,378
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-12-31	No
Administrative expenses professional fees incurred	2013-12-31	$6,012
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$500,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$1,158,721
Income. Received or receivable in cash from other sources (including rollovers)	2013-12-31	$335,389
Total non interest bearing cash at end of year	2013-12-31	$7,914
Total non interest bearing cash at beginning of year	2013-12-31	$38,492
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$1,624,150
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$9,774,269
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$8,150,119
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2013-12-31	$9,705,210
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2013-12-31	$0
Value of interest in pooled separate accounts at end of year	2013-12-31	$0
Value of interest in pooled separate accounts at beginning of year	2013-12-31	$7,858,680
Interest earned on other investments	2013-12-31	$1,378
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$61,145
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$110,298
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2013-12-31	$1,385,579
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	No
Was there a failure to transmit to the plan any participant contributions	2013-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Employer contributions (assets) at end of year	2013-12-31	$0
Employer contributions (assets) at beginning of year	2013-12-31	$142,649
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$1,250,335
Did the plan have assets held for investment	2013-12-31	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	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2013-12-31	Disclaimer
Accountancy firm name	2013-12-31	DIXON HUGHES GOODMAN LLP
Accountancy firm EIN	2013-12-31	560747981
2012 : AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2012 401k financial data
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total income from all sources (including contributions)	2012-12-31	$2,378,980
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$1,433,757
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$1,421,820
Value of total corrective distributions	2012-12-31	$2,834
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$1,451,336
Value of total assets at end of year	2012-12-31	$8,150,119
Value of total assets at beginning of year	2012-12-31	$7,204,896
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$9,103
Total interest from all sources	2012-12-31	$1,591
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Administrative expenses professional fees incurred	2012-12-31	$6,613
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$500,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$1,144,245
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$150,644
Administrative expenses (other) incurred	2012-12-31	$13
Total non interest bearing cash at end of year	2012-12-31	$38,492
Total non interest bearing cash at beginning of year	2012-12-31	$15,195
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$945,223
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$8,150,119
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$7,204,896
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest in pooled separate accounts at end of year	2012-12-31	$7,858,680
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$6,910,420
Interest earned on other investments	2012-12-31	$1,591
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$110,298
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$104,406
Net investment gain/loss from pooled separate accounts	2012-12-31	$926,053
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$156,447
Employer contributions (assets) at end of year	2012-12-31	$142,649
Employer contributions (assets) at beginning of year	2012-12-31	$174,875
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$1,421,820
Contract administrator fees	2012-12-31	$2,477
Did the plan have assets held for investment	2012-12-31	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	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	DIXON HUGHES GOODMAN LLP
Accountancy firm EIN	2012-12-31	560747981
2011 : AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2011 401k financial data
Total unrealized appreciation/depreciation of assets	2011-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$1,926
Total income from all sources (including contributions)	2011-12-31	$1,676,188
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$737,192
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$673,109
Value of total corrective distributions	2011-12-31	$2,336
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$1,826,798
Value of total assets at end of year	2011-12-31	$7,204,896
Value of total assets at beginning of year	2011-12-31	$6,267,826
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$61,747
Total interest from all sources	2011-12-31	$2,042
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Administrative expenses professional fees incurred	2011-12-31	$61,747
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$500,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$1,293,786
Income. Received or receivable in cash from other sources (including rollovers)	2011-12-31	$358,137
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2011-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2011-12-31	$1,926
Total non interest bearing cash at end of year	2011-12-31	$15,195
Total non interest bearing cash at beginning of year	2011-12-31	$31,373
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$938,996
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$7,204,896
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$6,265,900
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest in pooled separate accounts at end of year	2011-12-31	$6,910,420
Value of interest in pooled separate accounts at beginning of year	2011-12-31	$5,994,479
Interest earned on other investments	2011-12-31	$2,042
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$104,406
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$108,993
Net investment gain/loss from pooled separate accounts	2011-12-31	$-152,652
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	No
Was there a failure to transmit to the plan any participant contributions	2011-12-31	No
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Contributions received in cash from employer	2011-12-31	$174,875
Employer contributions (assets) at end of year	2011-12-31	$174,875
Employer contributions (assets) at beginning of year	2011-12-31	$132,981
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$673,109
Did the plan have assets held for investment	2011-12-31	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	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	DIXON HUGHES GOODMAN LLP
Accountancy firm EIN	2011-12-31	560747981
2010 : AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2010 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2010-12-31	$0
Total unrealized appreciation/depreciation of assets	2010-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$1,926
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$14,934
Total income from all sources (including contributions)	2010-12-31	$2,005,806
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$532,202
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$464,532
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$1,342,584
Value of total assets at end of year	2010-12-31	$6,267,826
Value of total assets at beginning of year	2010-12-31	$4,807,230
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$67,670
Total interest from all sources	2010-12-31	$2,428
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Administrative expenses professional fees incurred	2010-12-31	$0
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$500,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$1,148,646
Income. Received or receivable in cash from other sources (including rollovers)	2010-12-31	$59,294
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2010-12-31	$1,926
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2010-12-31	$14,934
Total non interest bearing cash at end of year	2010-12-31	$31,373
Total non interest bearing cash at beginning of year	2010-12-31	$17,215
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$1,473,604
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$6,265,900
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$4,792,296
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest in pooled separate accounts at end of year	2010-12-31	$5,994,479
Value of interest in pooled separate accounts at beginning of year	2010-12-31	$4,530,622
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2010-12-31	$2,428
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$108,993
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$125,533
Net investment gain/loss from pooled separate accounts	2010-12-31	$660,794
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$134,644
Employer contributions (assets) at end of year	2010-12-31	$132,981
Employer contributions (assets) at beginning of year	2010-12-31	$133,860
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$464,532
Contract administrator fees	2010-12-31	$67,670
Did the plan have assets held for investment	2010-12-31	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	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	DIXON HUGHES GOODMAN LLP
Accountancy firm EIN	2010-12-31	560747981
2009 : AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for AMERICAN HOSPICE MANAGEMENT 401(K) PLAN

2015: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: AMERICAN HOSPICE MANAGEMENT 401(K) PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

50147

Policy instance

Insurance contract or identification number	50147
Number of Individuals Covered	309
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $41,982
Total amount of fees paid to insurance company	USD $4,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,982
Insurance broker organization code?	3
Amount paid for insurance broker fees	4226
Additional information about fees paid to insurance broker	TPA FORUM COMPENSATION
Insurance broker name	LBA RETIREMENT PLAN SERVICES, LLC

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

50147

Policy instance

Insurance contract or identification number	50147
Number of Individuals Covered	430
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $46,756
Total amount of fees paid to insurance company	USD $4,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,756
Insurance broker organization code?	3
Amount paid for insurance broker fees	4690
Additional information about fees paid to insurance broker	TPA FORUM COMPENSATION
Insurance broker name	LBA RETIREMENT PLAN SERVICES, LLC

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

50147

Policy instance

Insurance contract or identification number	50147
Number of Individuals Covered	468
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $44,524
Total amount of fees paid to insurance company	USD $4,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,524
Insurance broker organization code?	3
Amount paid for insurance broker fees	4463
Additional information about fees paid to insurance broker	TPA FORUM COMPENSATION
Insurance broker name	LBA RETIREMENT PLAN SERVICES, LLC

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

50147

Policy instance

Insurance contract or identification number	50147
Number of Individuals Covered	473
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $36,685
Total amount of fees paid to insurance company	USD $4,437
Are there contracts with allocated funds for individual policies?	No
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	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 $36,685
Insurance broker organization code?	3
Amount paid for insurance broker fees	4372
Additional information about fees paid to insurance broker	TPA FORUM COMPENSATION
Insurance broker name	THE LBA GROUP

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

50147

Policy instance

Insurance contract or identification number	50147
Number of Individuals Covered	460
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $26,554
Total amount of fees paid to insurance company	USD $8,314
Are there contracts with allocated funds for individual policies?	No
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	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

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

50147

Policy instance

Insurance contract or identification number	50147
Number of Individuals Covered	406
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $20,326
Total amount of fees paid to insurance company	USD $6,147
Are there contracts with allocated funds for individual policies?	No
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	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 $20,326
Insurance broker organization code?	3
Amount paid for insurance broker fees	4033
Additional information about fees paid to insurance broker	TRANSACTION BASED FEES
Insurance broker name	LBA

Potentially related plans

AMERICAN HOSPICE FOUNDATION 403(B) RETIREMENT PLA [EIN = 521823611]

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Company Name:	AMERICAN HOSPICE MANAGEMENT
Employer identification number (EIN):	593154237
NAIC Classification:	621399
NAIC Description:	Offices of All Other Miscellaneous Health Practitioners