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| Plan Name | BLANKET ACCIDENT INSURANCE (HIV) PLAN |
| Plan identification number | 555 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | BAYSTATE HEALTH, INC. |
| Employer identification number (EIN): | 042105941 |
| NAIC Classification: | 622000 |
| NAIC Description: | Hospitals |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 555 | 2016-04-01 | DONNA BREWER | DONNA BREWER | 2017-10-13 | |
| 555 | 2016-04-01 | ||||
| 555 | 2015-04-01 | DONNA BREWER CEBS CMS RPA DIRECTOR | |||
| 555 | 2014-04-01 | CHRISTINE LESSARD CCP SPHR SHRM-SCP |
| Measure | Date | Value |
|---|---|---|
| 2016: BLANKET ACCIDENT INSURANCE (HIV) PLAN 2016 401k membership | ||
| Total participants, beginning-of-year | 2016-04-01 | 230 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-04-01 | 234 |
| Number of retired or separated participants receiving benefits | 2016-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-04-01 | 0 |
| Total of all active and inactive participants | 2016-04-01 | 234 |
| 2015: BLANKET ACCIDENT INSURANCE (HIV) PLAN 2015 401k membership | ||
| Total participants, beginning-of-year | 2015-04-01 | 1,233 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-04-01 | 142 |
| Total of all active and inactive participants | 2015-04-01 | 142 |
| 2014: BLANKET ACCIDENT INSURANCE (HIV) PLAN 2014 401k membership | ||
| Total participants, beginning-of-year | 2014-04-01 | 1,233 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-04-01 | 1,233 |
| Total of all active and inactive participants | 2014-04-01 | 1,233 |
| 2016: BLANKET ACCIDENT INSURANCE (HIV) PLAN 2016 form 5500 responses | ||
|---|---|---|
| 2016-04-01 | Type of plan entity | Single employer plan |
| 2016-04-01 | Submission has been amended | No |
| 2016-04-01 | This submission is the final filing | No |
| 2016-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-04-01 | Plan is a collectively bargained plan | No |
| 2016-04-01 | Plan funding arrangement – Insurance | Yes |
| 2016-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: BLANKET ACCIDENT INSURANCE (HIV) PLAN 2015 form 5500 responses | ||
| 2015-04-01 | Type of plan entity | Single employer plan |
| 2015-04-01 | Submission has been amended | No |
| 2015-04-01 | This submission is the final filing | No |
| 2015-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-04-01 | Plan is a collectively bargained plan | No |
| 2015-04-01 | Plan funding arrangement – Insurance | Yes |
| 2015-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: BLANKET ACCIDENT INSURANCE (HIV) PLAN 2014 form 5500 responses | ||
| 2014-04-01 | Type of plan entity | Single employer plan |
| 2014-04-01 | First time form 5500 has been submitted | Yes |
| 2014-04-01 | Submission has been amended | No |
| 2014-04-01 | This submission is the final filing | No |
| 2014-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-04-01 | Plan is a collectively bargained plan | No |
| 2014-04-01 | Plan funding arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – Insurance | Yes |
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | PTP NO 4964378 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | PTP NO 4964378 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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