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| Plan Name | HDHP SUPPLEMENTAL INSURANCE |
| Plan identification number | 510 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | OLEAN GENERAL HOSPITAL |
| Employer identification number (EIN): | 160743102 |
| NAIC Classification: | 622000 |
| NAIC Description: | Hospitals |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 510 | 2017-01-01 | JOYCE MARTINEZ | |||
| 510 | 2016-01-01 | JOYCE MARTINEZ | JOYCE MARTINEZ | 2017-07-28 |
| Measure | Date | Value |
|---|---|---|
| 2017: HDHP SUPPLEMENTAL INSURANCE 2017 401k membership | ||
| Total participants, beginning-of-year | 2017-01-01 | 171 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 152 |
| Total of all active and inactive participants | 2017-01-01 | 152 |
| Total participants | 2017-01-01 | 152 |
| 2016: HDHP SUPPLEMENTAL INSURANCE 2016 401k membership | ||
| Total participants, beginning-of-year | 2016-01-01 | 204 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 171 |
| Total of all active and inactive participants | 2016-01-01 | 171 |
| Total participants | 2016-01-01 | 171 |
| 2017: HDHP SUPPLEMENTAL INSURANCE 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 benefit arrangement – Insurance | Yes |
| 2016: HDHP SUPPLEMENTAL INSURANCE 2016 form 5500 responses | ||
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | First time form 5500 has been submitted | Yes |
| 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 benefit arrangement – Insurance | Yes |
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) | |
| Policy contract number | E4378857 |
| Policy instance | 1 |
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