401k Plan data: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL plan

TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 401k Plan overview

Plan Name	TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL
Plan identification number	010

TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

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 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.
Code section 403(b)(7) accounts - See Limited Pension Plan Reporting instructions for Code section 403(b)(7) custodial accounts for regulated investment company stock for certain exempt organizations.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

VERITY HEALTH SYSTEM has sponsored the creation of one or more 401k plans.

Company Name: VERITY HEALTH SYSTEM

Employer identification number (EIN): 912145484

NAIC Classification: 622000
NAIC Description: Hospitals

Additional information about VERITY HEALTH SYSTEM

Jurisdiction of Incorporation: California Department of State

Incorporation Date:

Company Identification Number: C2346440

More information about VERITY HEALTH SYSTEM

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
010 2021-01-01 PETER CHADWICK 2021-06-14 PETER CHADWICK 2021-06-14
010 2020-01-01 PETER CHADWICK 2021-06-14 PETER CHADWICK 2021-06-14
010 2019-01-01 PETER CHADWICK 2021-06-14 PETER CHADWICK 2021-06-14
010 2018-01-01 PETER CHADWICK 2021-06-14 PETER CHADWICK 2021-06-14
010 2017-01-01 PETER CHADWICK 2021-06-14 PETER CHADWICK 2021-06-14
010 2016-01-01 PETER CHADWICK 2021-06-14 PETER CHADWICK 2021-06-14
010 2015-12-14 PETER CHADWICK 2021-06-14 PETER CHADWICK 2021-06-14

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
010	2021-01-01	PETER CHADWICK	2021-06-14	PETER CHADWICK	2021-06-14
010	2020-01-01	PETER CHADWICK	2021-06-14	PETER CHADWICK	2021-06-14
010	2019-01-01	PETER CHADWICK	2021-06-14	PETER CHADWICK	2021-06-14
010	2018-01-01	PETER CHADWICK	2021-06-14	PETER CHADWICK	2021-06-14
010	2017-01-01	PETER CHADWICK	2021-06-14	PETER CHADWICK	2021-06-14
010	2016-01-01	PETER CHADWICK	2021-06-14	PETER CHADWICK	2021-06-14
010	2015-12-14	PETER CHADWICK	2021-06-14	PETER CHADWICK	2021-06-14

Plan Statistics for TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL

401k plan membership statisitcs for TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL

Measure Date Value
2021: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2021 401k membership
Total participants, beginning-of-year 2021-01-01 119
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 0
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 0
Number of participants with account balances 2021-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2020 401k membership
Total participants, beginning-of-year 2020-01-01 122
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 0
Number of retired or separated participants receiving benefits 2020-01-01 11
Number of other retired or separated participants entitled to future benefits 2020-01-01 108
Total of all active and inactive participants 2020-01-01 119
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 119
Number of participants with account balances 2020-01-01 119
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2019 401k membership
Total participants, beginning-of-year 2019-01-01 130
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
Number of retired or separated participants receiving benefits 2019-01-01 11
Number of other retired or separated participants entitled to future benefits 2019-01-01 111
Total of all active and inactive participants 2019-01-01 122
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 122
Number of participants with account balances 2019-01-01 122
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2018: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2018 401k membership
Total participants, beginning-of-year 2018-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 9
Number of retired or separated participants receiving benefits 2018-01-01 13
Number of other retired or separated participants entitled to future benefits 2018-01-01 108
Total of all active and inactive participants 2018-01-01 130
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 130
Number of participants with account balances 2018-01-01 130
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 0
2017: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2017 401k membership
Total participants, beginning-of-year 2017-01-01 141
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 10
Number of retired or separated participants receiving benefits 2017-01-01 13
Number of other retired or separated participants entitled to future benefits 2017-01-01 110
Total of all active and inactive participants 2017-01-01 133
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 133
Number of participants with account balances 2017-01-01 133
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2016 401k membership
Total participants, beginning-of-year 2016-01-01 144
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 12
Number of retired or separated participants receiving benefits 2016-01-01 12
Number of other retired or separated participants entitled to future benefits 2016-01-01 117
Total of all active and inactive participants 2016-01-01 141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 141
Number of participants with account balances 2016-01-01 141
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2015 401k membership
Total participants, beginning-of-year 2015-12-14 144
Total number of active participants reported on line 7a of the Form 5500 2015-12-14 14
Number of retired or separated participants receiving benefits 2015-12-14 6
Number of other retired or separated participants entitled to future benefits 2015-12-14 124
Total of all active and inactive participants 2015-12-14 144
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-12-14 0
Total participants 2015-12-14 144
Number of participants with account balances 2015-12-14 144
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-12-14 0

Measure	Date	Value
2021: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2021 401k membership
Total participants, beginning-of-year	2021-01-01	119
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	0
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	0
Number of participants with account balances	2021-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2020 401k membership
Total participants, beginning-of-year	2020-01-01	122
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	0
Number of retired or separated participants receiving benefits	2020-01-01	11
Number of other retired or separated participants entitled to future benefits	2020-01-01	108
Total of all active and inactive participants	2020-01-01	119
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	119
Number of participants with account balances	2020-01-01	119
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2019 401k membership
Total participants, beginning-of-year	2019-01-01	130
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	11
Number of other retired or separated participants entitled to future benefits	2019-01-01	111
Total of all active and inactive participants	2019-01-01	122
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	122
Number of participants with account balances	2019-01-01	122
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2018: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2018 401k membership
Total participants, beginning-of-year	2018-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	9
Number of retired or separated participants receiving benefits	2018-01-01	13
Number of other retired or separated participants entitled to future benefits	2018-01-01	108
Total of all active and inactive participants	2018-01-01	130
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	130
Number of participants with account balances	2018-01-01	130
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0
2017: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2017 401k membership
Total participants, beginning-of-year	2017-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	10
Number of retired or separated participants receiving benefits	2017-01-01	13
Number of other retired or separated participants entitled to future benefits	2017-01-01	110
Total of all active and inactive participants	2017-01-01	133
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	133
Number of participants with account balances	2017-01-01	133
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2016 401k membership
Total participants, beginning-of-year	2016-01-01	144
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	12
Number of retired or separated participants receiving benefits	2016-01-01	12
Number of other retired or separated participants entitled to future benefits	2016-01-01	117
Total of all active and inactive participants	2016-01-01	141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	141
Number of participants with account balances	2016-01-01	141
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2015 401k membership
Total participants, beginning-of-year	2015-12-14	144
Total number of active participants reported on line 7a of the Form 5500	2015-12-14	14
Number of retired or separated participants receiving benefits	2015-12-14	6
Number of other retired or separated participants entitled to future benefits	2015-12-14	124
Total of all active and inactive participants	2015-12-14	144
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-12-14	0
Total participants	2015-12-14	144
Number of participants with account balances	2015-12-14	144
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-12-14	0

Financial Data on TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL

Measure	Date	Value
2021 : TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-05-26	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-05-26	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-05-26	$0
Total income from all sources (including contributions)	2021-05-26	$9,895
Total loss/gain on sale of assets	2021-05-26	$0
Total of all expenses incurred	2021-05-26	$469,365
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-05-26	$469,365
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-05-26	$0
Value of total assets at end of year	2021-05-26	$0
Value of total assets at beginning of year	2021-05-26	$459,470
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-05-26	$0
Total interest from all sources	2021-05-26	$4,112
Total dividends received (eg from common stock, registered investment company shares)	2021-05-26	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-05-26	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2021-05-26	$0
Was this plan covered by a fidelity bond	2021-05-26	Yes
Value of fidelity bond cover	2021-05-26	$10,000,000
If this is an individual account plan, was there a blackout period	2021-05-26	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-05-26	$0
Were there any nonexempt tranactions with any party-in-interest	2021-05-26	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-05-26	No
Value of net income/loss	2021-05-26	$-459,470
Value of net assets at end of year (total assets less liabilities)	2021-05-26	$0
Value of net assets at beginning of year (total assets less liabilities)	2021-05-26	$459,470
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-05-26	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-05-26	No
Were any leases to which the plan was party in default or uncollectible	2021-05-26	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-05-26	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-05-26	$75,479
Interest earned on other investments	2021-05-26	$4,112
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-05-26	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-05-26	$383,991
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-05-26	$5,783
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-05-26	No
Was there a failure to transmit to the plan any participant contributions	2021-05-26	No
Has the plan failed to provide any benefit when due under the plan	2021-05-26	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-05-26	$469,365
Did the plan have assets held for investment	2021-05-26	No
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	2021-05-26	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-05-26	Yes
Opinion of an independent qualified public accountant for this plan	2021-05-26	Disclaimer
Accountancy firm name	2021-05-26	MOSS ADAMS LLP
Accountancy firm EIN	2021-05-26	910189318
2020 : TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$24,741
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$9,749
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$9,749
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$0
Value of total assets at end of year	2020-12-31	$459,470
Value of total assets at beginning of year	2020-12-31	$444,478
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$0
Total interest from all sources	2020-12-31	$11,331
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2020-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$14,992
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$459,470
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$444,478
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$75,479
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$62,381
Interest earned on other investments	2020-12-31	$11,331
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$383,991
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-12-31	$382,097
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$13,410
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$9,749
Did the plan have assets held for investment	2020-12-31	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	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Disclaimer
Accountancy firm name	2020-12-31	MOSS ADAMS LLP
Accountancy firm EIN	2020-12-31	910189318
2019 : TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$23,597
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$40,032
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$40,032
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$0
Value of total assets at end of year	2019-12-31	$444,478
Value of total assets at beginning of year	2019-12-31	$460,913
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$0
Total interest from all sources	2019-12-31	$11,815
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$-16,435
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$444,478
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$460,913
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$62,381
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$53,223
Interest earned on other investments	2019-12-31	$11,815
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$382,097
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$407,690
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$11,782
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$40,032
Did the plan have assets held for investment	2019-12-31	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	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	MOSS ADAMS LLP
Accountancy firm EIN	2019-12-31	910189318
2018 : TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total income from all sources (including contributions)	2018-12-31	$7,452
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$13,326
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$13,326
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$0
Value of total assets at end of year	2018-12-31	$460,913
Value of total assets at beginning of year	2018-12-31	$466,787
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$0
Total interest from all sources	2018-12-31	$12,078
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$-5,874
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$460,913
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$466,787
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$53,223
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$59,984
Interest earned on other investments	2018-12-31	$12,078
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-12-31	$407,690
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-12-31	$406,803
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-4,626
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$13,326
Did the plan have assets held for investment	2018-12-31	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	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	MOSS ADAMS LLP
Accountancy firm EIN	2018-12-31	910189318
2017 : TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total income from all sources (including contributions)	2017-12-31	$21,966
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$33,100
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$33,100
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$0
Value of total assets at end of year	2017-12-31	$466,787
Value of total assets at beginning of year	2017-12-31	$477,921
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$0
Total interest from all sources	2017-12-31	$12,313
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$-11,134
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$466,787
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$477,921
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2017-12-31	$59,984
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-12-31	$53,215
Interest earned on other investments	2017-12-31	$12,313
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2017-12-31	$406,803
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2017-12-31	$424,706
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-12-31	$9,653
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	No
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$33,100
Did the plan have assets held for investment	2017-12-31	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	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	MOSS ADAMS
Accountancy firm EIN	2017-12-31	910189318
2016 : TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total income from all sources (including contributions)	2016-12-31	$14,658
Total loss/gain on sale of assets	2016-12-31	$0
Total of all expenses incurred	2016-12-31	$13,062
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$13,062
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$0
Value of total assets at end of year	2016-12-31	$477,921
Value of total assets at beginning of year	2016-12-31	$476,325
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$0
Total interest from all sources	2016-12-31	$12,537
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2016-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Value of net income/loss	2016-12-31	$1,596
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$477,921
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$476,325
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2016-12-31	$53,215
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2016-12-31	$52,915
Interest earned on other investments	2016-12-31	$12,537
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2016-12-31	$424,706
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2016-12-31	$423,410
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2016-12-31	$2,121
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	No
Was there a failure to transmit to the plan any participant contributions	2016-12-31	No
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$13,062
Did the plan have assets held for investment	2016-12-31	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	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
Opinion of an independent qualified public accountant for this plan	2016-12-31	Disclaimer
Accountancy firm name	2016-12-31	MOSS ADAMS
Accountancy firm EIN	2016-12-31	910189318
2015 : TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2015 401k financial data
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
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	$-422
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$1,716
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$1,716
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$0
Value of total assets at end of year	2015-12-31	$476,325
Value of total assets at beginning of year	2015-12-31	$478,463
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$0
Total interest from all sources	2015-12-31	$1,063
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
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	$-2,138
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$476,325
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$478,463
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	$52,915
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$54,589
Interest earned on other investments	2015-12-31	$1,063
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-12-31	$423,410
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$423,874
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$-1,485
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	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$1,716
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
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	MOSS ADAMS LLP
Accountancy firm EIN	2015-12-31	910189318

Form 5500 Responses for TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL

2021: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	Yes
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 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 funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
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 funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
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 funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: TAX SHELTERED ANNUITY PLAN FOR NURSES OF O'CONNOR HOSPITAL 2015 form 5500 responses
2015-12-14	Type of plan entity	Single employer plan
2015-12-14	First time form 5500 has been submitted	Yes
2015-12-14	Submission has been amended	No
2015-12-14	This submission is the final filing	No
2015-12-14	This return/report is a short plan year return/report (less than 12 months)	Yes
2015-12-14	Plan is a collectively bargained plan	No
2015-12-14	Plan funding arrangement – Insurance	Yes
2015-12-14	Plan funding arrangement – Trust	Yes
2015-12-14	Plan benefit arrangement – Insurance	Yes
2015-12-14	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

VARIABLE ANNUITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70238 )

Policy contract number

40796

Policy instance

Insurance contract or identification number	40796
Number of Individuals Covered	0
Insurance policy start date	2021-01-01
Insurance policy end date	2021-05-26
Total amount of commissions paid to insurance broker	USD $16
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	1
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 $16
Insurance broker organization code?	3

VARIABLE ANNUITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70238 )

Policy contract number

40796

Policy instance

Insurance contract or identification number	40796
Number of Individuals Covered	119
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $35
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	1
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 $35
Insurance broker organization code?	3

VARIABLE ANNUITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70238 )

Policy contract number

40796

Policy instance

Insurance contract or identification number	40796
Number of Individuals Covered	122
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $24
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	1
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 $24
Insurance broker organization code?	3

VARIABLE ANNUITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70238 )

Policy contract number

40796

Policy instance

Insurance contract or identification number	40796
Number of Individuals Covered	130
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $31
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	1
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 $31
Insurance broker organization code?	3

VARIABLE ANNUITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70238 )

Policy contract number

40796

Policy instance

Insurance contract or identification number	40796
Number of Individuals Covered	133
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $29
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	1
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 $29
Insurance broker organization code?	3

VARIABLE ANNUITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70238 )

Policy contract number

40796

Policy instance

Insurance contract or identification number	40796
Number of Individuals Covered	141
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $25
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	1
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 $25
Insurance broker organization code?	3

VARIABLE ANNUITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70238 )

Policy contract number

40796

Policy instance

Insurance contract or identification number	40796
Number of Individuals Covered	144
Insurance policy start date	2015-12-14
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
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	1
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

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Company Name:	VERITY HEALTH SYSTEM
Employer identification number (EIN):	912145484
NAIC Classification:	622000
NAIC Description:	Hospitals

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	C2346440