| Plan Name | MEDICAL PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
|
| Company Name: | HEMPHILL COUNTY HOSPITAL DISTRICT |
| Employer identification number (EIN): | 756002888 |
| NAIC Classification: | 622000 |
| NAIC Description: | Hospitals |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2021-01-01 | CHRISTY FRANCIS, CEO | 2023-01-04 |
| 2021: MEDICAL PLAN 2021 form 5500 responses | ||
|---|---|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | First time form 5500 has been submitted | Yes |
| 2021-01-01 | Submission has been amended | Yes |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) | |
| Policy contract number | 1122601 |
| Policy instance | 1 |