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GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 401k Plan overview

Plan NameGYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP)
Plan identification number 501

GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)

401k Sponsoring company profile

GYPSUM SYSTEMS MANAGEMENT, INC. has sponsored the creation of one or more 401k plans.

Company Name:GYPSUM SYSTEMS MANAGEMENT, INC.
Employer identification number (EIN):161062828
NAIC Classification:238300

Additional information about GYPSUM SYSTEMS MANAGEMENT, INC.

Jurisdiction of Incorporation: New York Department of State
Incorporation Date: 1975-09-24
Company Identification Number: 2231178
Legal Registered Office Address: 640 POUND ROAD
Erie
ELMA
United States of America (USA)
14059

More information about GYPSUM SYSTEMS MANAGEMENT, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP)

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-04-01KEVIN BLACKLEY2023-10-12 KEVIN BLACKLEY2023-10-12
5012021-04-01KEVIN BLACKLEY2022-08-03 KEVIN BLACKLEY2022-08-03
5012020-04-01KEVIN BLACKLEY2021-07-26 KEVIN BLACKLEY2021-07-26
5012019-04-01KEVIN BLACKLEY2020-11-03 KEVIN BLACKLEY2020-11-03
5012018-04-01KEVIN BLACKLEY2019-10-14 KEVIN BLACKLEY2019-10-14
5012017-04-01KEVIN BLACKLEY
5012016-04-01KEVIN BLACKLEY
5012015-04-01KEVIN BLACKLEY KEVIN BLACKLEY2017-08-17
5012014-04-01CHARLES RAPALJE VP
5012013-04-01CHARLES RAPALJE VP
5012012-04-01CHARLES RAPALJE
5012011-04-01CHARLES RAPALJE
5012010-04-01CHARLES RAPALJE
5012009-04-01CHARLES RAPALJE

Plan Statistics for GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP)

401k plan membership statisitcs for GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP)

Measure Date Value
2022: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2022 401k membership
Total participants, beginning-of-year2022-04-01115
Total number of active participants reported on line 7a of the Form 55002022-04-0190
Total of all active and inactive participants2022-04-0190
2021: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2021 401k membership
Total participants, beginning-of-year2021-04-01122
Total number of active participants reported on line 7a of the Form 55002021-04-01115
Total of all active and inactive participants2021-04-01115
2020: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2020 401k membership
Total participants, beginning-of-year2020-04-01133
Total number of active participants reported on line 7a of the Form 55002020-04-01122
Total of all active and inactive participants2020-04-01122
2019: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2019 401k membership
Total participants, beginning-of-year2019-04-01238
Total number of active participants reported on line 7a of the Form 55002019-04-01133
Total of all active and inactive participants2019-04-01133
Total participants2019-04-01133
2018: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2018 401k membership
Total participants, beginning-of-year2018-04-01293
Total number of active participants reported on line 7a of the Form 55002018-04-01238
Number of retired or separated participants receiving benefits2018-04-010
Number of other retired or separated participants entitled to future benefits2018-04-010
Total of all active and inactive participants2018-04-01238
Total participants2018-04-01238
2017: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2017 401k membership
Total participants, beginning-of-year2017-04-01284
Total number of active participants reported on line 7a of the Form 55002017-04-014,266
Total of all active and inactive participants2017-04-014,266
2016: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2016 401k membership
Total participants, beginning-of-year2016-04-01279
Total number of active participants reported on line 7a of the Form 55002016-04-01284
Total of all active and inactive participants2016-04-01284
2015: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2015 401k membership
Total participants, beginning-of-year2015-04-01274
Total number of active participants reported on line 7a of the Form 55002015-04-01279
Total of all active and inactive participants2015-04-01279
2014: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2014 401k membership
Total participants, beginning-of-year2014-04-01272
Total number of active participants reported on line 7a of the Form 55002014-04-01274
Number of retired or separated participants receiving benefits2014-04-010
Number of other retired or separated participants entitled to future benefits2014-04-010
Total of all active and inactive participants2014-04-01274
2013: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2013 401k membership
Total participants, beginning-of-year2013-04-01271
Total number of active participants reported on line 7a of the Form 55002013-04-01267
Number of retired or separated participants receiving benefits2013-04-010
Number of other retired or separated participants entitled to future benefits2013-04-010
Total of all active and inactive participants2013-04-01267
2012: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2012 401k membership
Total participants, beginning-of-year2012-04-01263
Total number of active participants reported on line 7a of the Form 55002012-04-01271
Total of all active and inactive participants2012-04-01271
Total participants2012-04-01271
2011: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2011 401k membership
Total participants, beginning-of-year2011-04-01249
Total number of active participants reported on line 7a of the Form 55002011-04-01263
Total of all active and inactive participants2011-04-01263
Total participants2011-04-01263
2010: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2010 401k membership
Total participants, beginning-of-year2010-04-01272
Total number of active participants reported on line 7a of the Form 55002010-04-01249
Number of retired or separated participants receiving benefits2010-04-010
Number of other retired or separated participants entitled to future benefits2010-04-010
Total of all active and inactive participants2010-04-01249
Total participants2010-04-01249
2009: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2009 401k membership
Total participants, beginning-of-year2009-04-010
Total number of active participants reported on line 7a of the Form 55002009-04-01272
Number of retired or separated participants receiving benefits2009-04-010
Number of other retired or separated participants entitled to future benefits2009-04-010
Total of all active and inactive participants2009-04-01272
Total participants2009-04-01272

Form 5500 Responses for GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP)

2022: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2022 form 5500 responses
2022-04-01Type of plan entitySingle employer plan
2022-04-01Plan funding arrangement – General assets of the sponsorYes
2022-04-01Plan benefit arrangement – General assets of the sponsorYes
2021: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2021 form 5500 responses
2021-04-01Type of plan entitySingle employer plan
2021-04-01Plan funding arrangement – General assets of the sponsorYes
2021-04-01Plan benefit arrangement – General assets of the sponsorYes
2020: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2020 form 5500 responses
2020-04-01Type of plan entitySingle employer plan
2020-04-01Plan funding arrangement – General assets of the sponsorYes
2020-04-01Plan benefit arrangement – General assets of the sponsorYes
2019: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2019 form 5500 responses
2019-04-01Type of plan entitySingle employer plan
2019-04-01Plan funding arrangement – General assets of the sponsorYes
2019-04-01Plan benefit arrangement – General assets of the sponsorYes
2018: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2018 form 5500 responses
2018-04-01Type of plan entitySingle employer plan
2018-04-01Plan funding arrangement – General assets of the sponsorYes
2018-04-01Plan benefit arrangement – General assets of the sponsorYes
2017: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2017 form 5500 responses
2017-04-01Type of plan entitySingle employer plan
2017-04-01Plan funding arrangement – InsuranceYes
2017-04-01Plan funding arrangement – General assets of the sponsorYes
2017-04-01Plan benefit arrangement – InsuranceYes
2017-04-01Plan benefit arrangement – General assets of the sponsorYes
2016: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01Plan funding arrangement – InsuranceYes
2016-04-01Plan funding arrangement – General assets of the sponsorYes
2016-04-01Plan benefit arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – General assets of the sponsorYes
2015: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01Submission has been amendedYes
2015-04-01Plan funding arrangement – InsuranceYes
2015-04-01Plan funding arrangement – General assets of the sponsorYes
2015-04-01Plan benefit arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – General assets of the sponsorYes
2014: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2014 form 5500 responses
2014-04-01Type of plan entitySingle employer plan
2014-04-01Plan funding arrangement – InsuranceYes
2014-04-01Plan funding arrangement – General assets of the sponsorYes
2014-04-01Plan benefit arrangement – InsuranceYes
2014-04-01Plan benefit arrangement – General assets of the sponsorYes
2013: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2013 form 5500 responses
2013-04-01Type of plan entitySingle employer plan
2013-04-01Plan funding arrangement – InsuranceYes
2013-04-01Plan funding arrangement – General assets of the sponsorYes
2013-04-01Plan benefit arrangement – InsuranceYes
2013-04-01Plan benefit arrangement – General assets of the sponsorYes
2012: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2012 form 5500 responses
2012-04-01Type of plan entitySingle employer plan
2012-04-01Submission has been amendedNo
2012-04-01This submission is the final filingNo
2012-04-01This return/report is a short plan year return/report (less than 12 months)No
2012-04-01Plan is a collectively bargained planNo
2012-04-01Plan funding arrangement – InsuranceYes
2012-04-01Plan funding arrangement – General assets of the sponsorYes
2012-04-01Plan benefit arrangement – InsuranceYes
2012-04-01Plan benefit arrangement – General assets of the sponsorYes
2011: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2011 form 5500 responses
2011-04-01Type of plan entitySingle employer plan
2011-04-01Submission has been amendedNo
2011-04-01This submission is the final filingNo
2011-04-01This return/report is a short plan year return/report (less than 12 months)No
2011-04-01Plan is a collectively bargained planNo
2011-04-01Plan funding arrangement – InsuranceYes
2011-04-01Plan funding arrangement – General assets of the sponsorYes
2011-04-01Plan benefit arrangement – InsuranceYes
2011-04-01Plan benefit arrangement – General assets of the sponsorYes
2010: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2010 form 5500 responses
2010-04-01Type of plan entitySingle employer plan
2010-04-01Submission has been amendedNo
2010-04-01This submission is the final filingNo
2010-04-01This return/report is a short plan year return/report (less than 12 months)No
2010-04-01Plan is a collectively bargained planNo
2010-04-01Plan funding arrangement – InsuranceYes
2010-04-01Plan funding arrangement – General assets of the sponsorYes
2010-04-01Plan benefit arrangement – InsuranceYes
2010-04-01Plan benefit arrangement – General assets of the sponsorYes
2009: GYPSUM SYSTEM, INC. CONSUMER DIRECTED HEALTH PLAN (CDHP) 2009 form 5500 responses
2009-04-01Type of plan entitySingle employer plan
2009-04-01First time form 5500 has been submittedYes
2009-04-01Submission has been amendedNo
2009-04-01This submission is the final filingNo
2009-04-01This return/report is a short plan year return/report (less than 12 months)No
2009-04-01Plan is a collectively bargained planNo
2009-04-01Plan funding arrangement – InsuranceYes
2009-04-01Plan funding arrangement – General assets of the sponsorYes
2009-04-01Plan benefit arrangement – InsuranceYes
2009-04-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL17622
Policy instance 2
Insurance contract or identification numberHCL17622
Number of Individuals Covered136
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $175,570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number13040
Policy instance 1
Insurance contract or identification number13040
Number of Individuals Covered4226
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Other welfare benefits providedHEALTH INSURANCE ADMINISTRATION
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker namePREMIER CONSULTING ASSOCIATES
INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number80160T
Policy instance 1
Insurance contract or identification number80160T
Number of Individuals Covered274
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Other welfare benefits providedHEALTH INSURANCE ADMINISTRATION
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL17622
Policy instance 2
Insurance contract or identification numberHCL17622
Number of Individuals Covered274
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $190,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL17622
Policy instance 2
Insurance contract or identification numberHCL17622
Number of Individuals Covered267
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $152,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number80160T
Policy instance 1
Insurance contract or identification number80160T
Number of Individuals Covered267
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Other welfare benefits providedHEALTH INSURANCE ADMINISTRATION
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number80160T
Policy instance 1
Insurance contract or identification number80160T
Number of Individuals Covered271
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHEALTH INSURANCE ADMINISTRATION
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
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL17622
Policy instance 2
Insurance contract or identification numberHCL17622
Number of Individuals Covered271
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $149,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL17622
Policy instance 1
Insurance contract or identification numberHCL17622
Number of Individuals Covered263
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $133,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number80160T
Policy instance 2
Insurance contract or identification number80160T
Number of Individuals Covered263
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHEALTH INSURANCE ADMINISTRATION
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
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL17622
Policy instance 1
Insurance contract or identification numberHCL17622
Number of Individuals Covered249
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $138,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees0
Insurance broker name
INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number80160T
Policy instance 2
Insurance contract or identification number80160T
Number of Individuals Covered249
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHELATH PLAN CLAIMS & ADMINISTRATION
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 BrokerUSD $0
Amount paid for insurance broker fees0
Insurance broker name
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL17622
Policy instance 1
Insurance contract or identification numberHCL17622
Number of Individuals Covered272
Insurance policy start date2009-01-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $130,619
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees0
Insurance broker name
INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number80160T
Policy instance 2
Insurance contract or identification number80160T
Number of Individuals Covered272
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHEALTH PLAN CLAIMS & ADMINISTRATION
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 BrokerUSD $0
Amount paid for insurance broker fees0
Insurance broker name

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