401k Plan data: BLUE MOUNTAIN HOSPITAL 403(B) PLAN plan

BLUE MOUNTAIN HOSPITAL 403(B) PLAN 401k Plan overview

Plan Name	BLUE MOUNTAIN HOSPITAL 403(B) PLAN
Plan identification number	001

BLUE MOUNTAIN HOSPITAL 403(B) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
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.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

BLUE MOUNTAIN HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name: BLUE MOUNTAIN HOSPITAL

Employer identification number (EIN): 200743054

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLUE MOUNTAIN HOSPITAL 403(B) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01
001 2021-01-01
001 2020-01-01
001 2019-01-01
001 2018-01-01 DERRILL KENT TUREK
001 2017-01-01 DERRILL KENT TUREK
001 2016-01-01 JIMMY JOHNSON
001 2015-01-01 JIMMY JOHNSON JIMMY JOHNSON 2016-05-31
001 2014-01-01 JIMMY JOHNSON JIMMY JOHNSON 2015-04-20
001 2013-01-01 JEREMY LYMAN JEREMY LYMAN 2014-05-29
001 2012-09-01 JEREMY LYMAN JEREMY LYMAN 2013-05-07

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
001	2022-01-01
001	2021-01-01
001	2020-01-01
001	2019-01-01
001	2018-01-01	DERRILL KENT TUREK
001	2017-01-01	DERRILL KENT TUREK
001	2016-01-01	JIMMY JOHNSON
001	2015-01-01	JIMMY JOHNSON	JIMMY JOHNSON	2016-05-31
001	2014-01-01	JIMMY JOHNSON	JIMMY JOHNSON	2015-04-20
001	2013-01-01	JEREMY LYMAN	JEREMY LYMAN	2014-05-29
001	2012-09-01	JEREMY LYMAN	JEREMY LYMAN	2013-05-07

Plan Statistics for BLUE MOUNTAIN HOSPITAL 403(B) PLAN

401k plan membership statisitcs for BLUE MOUNTAIN HOSPITAL 403(B) PLAN

Measure Date Value
2022: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 157
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 138
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 12
Total of all active and inactive participants 2022-01-01 150
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 150
Number of participants with account balances 2022-01-01 75
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 138
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 143
Number of retired or separated participants receiving benefits 2021-01-01 2
Number of other retired or separated participants entitled to future benefits 2021-01-01 12
Total of all active and inactive participants 2021-01-01 157
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 157
Number of participants with account balances 2021-01-01 73
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 1
2020: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 124
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 11
Total of all active and inactive participants 2020-01-01 135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 135
Number of participants with account balances 2020-01-01 65
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 106
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 115
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 13
Total of all active and inactive participants 2019-01-01 128
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 128
Number of participants with account balances 2019-01-01 63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 2
2018: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 93
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 84
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 12
Total of all active and inactive participants 2018-01-01 96
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 96
Number of participants with account balances 2018-01-01 63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 4
2017: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 97
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 87
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 6
Total of all active and inactive participants 2017-01-01 93
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 93
Number of participants with account balances 2017-01-01 60
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 3
2016: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 89
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 86
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 11
Total of all active and inactive participants 2016-01-01 97
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 97
Number of participants with account balances 2016-01-01 63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 80
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 68
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 10
Total of all active and inactive participants 2015-01-01 78
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 78
Number of participants with account balances 2015-01-01 57
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 1
2014: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 87
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 70
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 6
Total of all active and inactive participants 2014-01-01 76
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 76
Number of participants with account balances 2014-01-01 44
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 2
2013: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 82
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 84
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 3
Total of all active and inactive participants 2013-01-01 87
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 87
Number of participants with account balances 2013-01-01 40
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 1
2012: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2012 401k membership
Total participants, beginning-of-year 2012-09-01 74
Total number of active participants reported on line 7a of the Form 5500 2012-09-01 78
Number of retired or separated participants receiving benefits 2012-09-01 0
Number of other retired or separated participants entitled to future benefits 2012-09-01 1
Total of all active and inactive participants 2012-09-01 79
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-09-01 0
Total participants 2012-09-01 79
Number of participants with account balances 2012-09-01 33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-09-01 1

Measure	Date	Value
2022: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	157
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	138
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	12
Total of all active and inactive participants	2022-01-01	150
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	150
Number of participants with account balances	2022-01-01	75
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	138
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	143
Number of retired or separated participants receiving benefits	2021-01-01	2
Number of other retired or separated participants entitled to future benefits	2021-01-01	12
Total of all active and inactive participants	2021-01-01	157
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	157
Number of participants with account balances	2021-01-01	73
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	1
2020: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	124
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	11
Total of all active and inactive participants	2020-01-01	135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	135
Number of participants with account balances	2020-01-01	65
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	106
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	115
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	13
Total of all active and inactive participants	2019-01-01	128
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	128
Number of participants with account balances	2019-01-01	63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	2
2018: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	93
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	84
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	12
Total of all active and inactive participants	2018-01-01	96
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	96
Number of participants with account balances	2018-01-01	63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	4
2017: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	97
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	87
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	6
Total of all active and inactive participants	2017-01-01	93
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	93
Number of participants with account balances	2017-01-01	60
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	3
2016: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	89
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	86
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	11
Total of all active and inactive participants	2016-01-01	97
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	97
Number of participants with account balances	2016-01-01	63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	80
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	68
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	10
Total of all active and inactive participants	2015-01-01	78
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	78
Number of participants with account balances	2015-01-01	57
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	1
2014: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	87
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	70
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	6
Total of all active and inactive participants	2014-01-01	76
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	76
Number of participants with account balances	2014-01-01	44
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	2
2013: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	82
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	84
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	3
Total of all active and inactive participants	2013-01-01	87
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	87
Number of participants with account balances	2013-01-01	40
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	1
2012: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2012 401k membership
Total participants, beginning-of-year	2012-09-01	74
Total number of active participants reported on line 7a of the Form 5500	2012-09-01	78
Number of retired or separated participants receiving benefits	2012-09-01	0
Number of other retired or separated participants entitled to future benefits	2012-09-01	1
Total of all active and inactive participants	2012-09-01	79
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-09-01	0
Total participants	2012-09-01	79
Number of participants with account balances	2012-09-01	33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-09-01	1

Financial Data on BLUE MOUNTAIN HOSPITAL 403(B) PLAN

Measure	Date	Value
2022 : BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$31,204
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$105,159
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$75,104
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$471,879
Value of total assets at end of year	2022-12-31	$2,954,849
Value of total assets at beginning of year	2022-12-31	$3,028,804
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$30,055
Total interest from all sources	2022-12-31	$8,448
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$0
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$3,000,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$285,043
Participant contributions at end of year	2022-12-31	$166,423
Participant contributions at beginning of year	2022-12-31	$213,835
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$14,668
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2022-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2022-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-73,955
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$2,954,849
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$3,028,804
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$2,726,651
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$2,730,964
Interest on participant loans	2022-12-31	$7,611
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2022-12-31	$837
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$61,775
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$84,005
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-449,123
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$172,168
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$75,104
Contract administrator fees	2022-12-31	$30,055
Did the plan have assets held for investment	2022-12-31	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	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	DINGUS, ZARECOR AND ASSOCIATES PLLC
Accountancy firm EIN	2022-12-31	200079326
2021 : BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$2,377
Total income from all sources (including contributions)	2021-12-31	$725,015
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$143,090
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$114,172
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$433,748
Value of total assets at end of year	2021-12-31	$3,028,804
Value of total assets at beginning of year	2021-12-31	$2,449,256
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$28,918
Total interest from all sources	2021-12-31	$8,219
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$3,000,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$264,589
Participant contributions at end of year	2021-12-31	$213,835
Participant contributions at beginning of year	2021-12-31	$115,185
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$3,626
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2021-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2021-12-31	$2,377
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$581,925
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$3,028,804
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$2,446,879
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$2,730,964
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$2,260,266
Interest on participant loans	2021-12-31	$8,219
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$84,005
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$73,805
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$283,048
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$165,533
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$114,172
Contract administrator fees	2021-12-31	$28,918
Did the plan have assets held for investment	2021-12-31	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	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	WSRP, LLC
Accountancy firm EIN	2021-12-31	870517754
2020 : BLUE MOUNTAIN HOSPITAL 403(B) PLAN 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	$2,377
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	$715,230
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$36,181
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$12,663
Value of total corrective distributions	2020-12-31	$2,377
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$387,908
Value of total assets at end of year	2020-12-31	$2,449,256
Value of total assets at beginning of year	2020-12-31	$1,767,830
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$21,141
Total interest from all sources	2020-12-31	$5,947
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$3,000,000
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
Contributions received from participants	2020-12-31	$236,656
Participant contributions at end of year	2020-12-31	$115,185
Participant contributions at beginning of year	2020-12-31	$90,059
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$6,854
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2020-12-31	$2,377
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2020-12-31	$0
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	$679,049
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$2,446,879
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$1,767,830
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	$2,260,266
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$1,615,683
Interest on participant loans	2020-12-31	$5,947
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$73,805
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-12-31	$62,088
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$321,375
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	Yes
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$144,398
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$12,663
Contract administrator fees	2020-12-31	$21,141
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	WSRP, LLC
Accountancy firm EIN	2020-12-31	870517754
2019 : BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2019 401k financial data
Total income from all sources	2019-12-31	$595,255
Expenses. Total of all expenses incurred	2019-12-31	$98,412
Benefits paid (including direct rollovers)	2019-12-31	$96,939
Total plan assets at end of year	2019-12-31	$1,767,830
Total plan assets at beginning of year	2019-12-31	$1,270,987
Value of fidelity bond covering the plan	2019-12-31	$3,000,000
Total contributions received or receivable from participants	2019-12-31	$193,093
Expenses. Other expenses not covered elsewhere	2019-12-31	$1,473
Other income received	2019-12-31	$278,938
Net income (gross income less expenses)	2019-12-31	$496,843
Net plan assets at end of year (total assets less liabilities)	2019-12-31	$1,767,830
Net plan assets at beginning of year (total assets less liabilities)	2019-12-31	$1,270,987
Assets. Value of participant loans	2019-12-31	$90,059
Total contributions received or receivable from employer(s)	2019-12-31	$123,224
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
2018 : BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2018 401k financial data
Total income from all sources	2018-12-31	$208,546
Expenses. Total of all expenses incurred	2018-12-31	$153,642
Benefits paid (including direct rollovers)	2018-12-31	$151,282
Total plan assets at end of year	2018-12-31	$1,270,987
Total plan assets at beginning of year	2018-12-31	$1,216,083
Value of fidelity bond covering the plan	2018-12-31	$3,000,000
Total contributions received or receivable from participants	2018-12-31	$185,604
Expenses. Other expenses not covered elsewhere	2018-12-31	$2,360
Noncash contributions received	2018-12-31	$-97,090
Net income (gross income less expenses)	2018-12-31	$54,904
Net plan assets at end of year (total assets less liabilities)	2018-12-31	$1,270,987
Net plan assets at beginning of year (total assets less liabilities)	2018-12-31	$1,216,083
Assets. Value of participant loans	2018-12-31	$72,068
Total contributions received or receivable from employer(s)	2018-12-31	$120,032
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
2017 : BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2017 401k financial data
Total income from all sources	2017-12-31	$385,278
Expenses. Total of all expenses incurred	2017-12-31	$39,693
Benefits paid (including direct rollovers)	2017-12-31	$37,691
Total plan assets at end of year	2017-12-31	$1,216,083
Total plan assets at beginning of year	2017-12-31	$870,498
Value of fidelity bond covering the plan	2017-12-31	$3,000,000
Total contributions received or receivable from participants	2017-12-31	$148,376
Other income received	2017-12-31	$128,504
Net income (gross income less expenses)	2017-12-31	$345,585
Net plan assets at end of year (total assets less liabilities)	2017-12-31	$1,216,083
Net plan assets at beginning of year (total assets less liabilities)	2017-12-31	$870,498
Assets. Value of participant loans	2017-12-31	$88,195
Total contributions received or receivable from employer(s)	2017-12-31	$108,398
Expenses. Administrative service providers (salaries,fees and commissions)	2017-12-31	$2,002
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
2016 : BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2016 401k financial data
Total income from all sources	2016-12-31	$295,382
Expenses. Total of all expenses incurred	2016-12-31	$78,767
Benefits paid (including direct rollovers)	2016-12-31	$77,517
Total plan assets at end of year	2016-12-31	$870,498
Total plan assets at beginning of year	2016-12-31	$653,883
Value of fidelity bond covering the plan	2016-12-31	$3,000,000
Total contributions received or receivable from participants	2016-12-31	$144,389
Contributions received from other sources (not participants or employers)	2016-12-31	$1,453
Other income received	2016-12-31	$42,437
Net income (gross income less expenses)	2016-12-31	$216,615
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$870,498
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$653,883
Assets. Value of participant loans	2016-12-31	$64,426
Total contributions received or receivable from employer(s)	2016-12-31	$107,103
Expenses. Administrative service providers (salaries,fees and commissions)	2016-12-31	$1,250
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0
2015 : BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2015 401k financial data
Total income from all sources	2015-12-31	$196,323
Expenses. Total of all expenses incurred	2015-12-31	$69,876
Benefits paid (including direct rollovers)	2015-12-31	$69,876
Total plan assets at end of year	2015-12-31	$653,883
Total plan assets at beginning of year	2015-12-31	$527,436
Value of fidelity bond covering the plan	2015-12-31	$3,000,000
Total contributions received or receivable from participants	2015-12-31	$124,573
Other income received	2015-12-31	$-18,508
Net income (gross income less expenses)	2015-12-31	$126,447
Net plan assets at end of year (total assets less liabilities)	2015-12-31	$653,883
Net plan assets at beginning of year (total assets less liabilities)	2015-12-31	$527,436
Assets. Value of participant loans	2015-12-31	$61,567
Total contributions received or receivable from employer(s)	2015-12-31	$90,258
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
2014 : BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2014 401k financial data
Total income from all sources	2014-12-31	$262,992
Expenses. Total of all expenses incurred	2014-12-31	$10,373
Benefits paid (including direct rollovers)	2014-12-31	$10,373
Total plan assets at end of year	2014-12-31	$527,436
Total plan assets at beginning of year	2014-12-31	$274,817
Value of fidelity bond covering the plan	2014-12-31	$3,000,000
Total contributions received or receivable from participants	2014-12-31	$109,347
Contributions received from other sources (not participants or employers)	2014-12-31	$57,365
Other income received	2014-12-31	$17,798
Net income (gross income less expenses)	2014-12-31	$252,619
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$527,436
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$274,817
Assets. Value of participant loans	2014-12-31	$12,625
Total contributions received or receivable from employer(s)	2014-12-31	$78,482
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
2013 : BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2013 401k financial data
Total income from all sources	2013-12-31	$202,249
Expenses. Total of all expenses incurred	2013-12-31	$170
Benefits paid (including direct rollovers)	2013-12-31	$170
Total plan assets at end of year	2013-12-31	$274,817
Total plan assets at beginning of year	2013-12-31	$72,738
Value of fidelity bond covering the plan	2013-12-31	$3,000,000
Total contributions received or receivable from participants	2013-12-31	$94,708
Contributions received from other sources (not participants or employers)	2013-12-31	$11,707
Other income received	2013-12-31	$27,031
Net income (gross income less expenses)	2013-12-31	$202,079
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$274,817
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$72,738
Total contributions received or receivable from employer(s)	2013-12-31	$68,803
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
2012 : BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2012 401k financial data
Total income from all sources	2012-12-31	$72,738
Total plan assets at end of year	2012-12-31	$72,738
Total plan assets at beginning of year	2012-12-31	$0
Total contributions received or receivable from participants	2012-12-31	$19,717
Contributions received from other sources (not participants or employers)	2012-12-31	$36,476
Other income received	2012-12-31	$1,903
Net income (gross income less expenses)	2012-12-31	$72,738
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$72,738
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$0
Total contributions received or receivable from employer(s)	2012-12-31	$14,642
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0

Form 5500 Responses for BLUE MOUNTAIN HOSPITAL 403(B) PLAN

2022: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 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	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
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: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 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: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 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 – Trust	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 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 – Trust	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 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 – Trust	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 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 – Trust	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: BLUE MOUNTAIN HOSPITAL 403(B) PLAN 2012 form 5500 responses
2012-09-01	Type of plan entity	Single employer plan
2012-09-01	First time form 5500 has been submitted	Yes
2012-09-01	Submission has been amended	No
2012-09-01	This submission is the final filing	No
2012-09-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2012-09-01	Plan is a collectively bargained plan	No
2012-09-01	Plan funding arrangement – Trust	Yes
2012-09-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

786-80081

Policy instance

Insurance contract or identification number	786-80081
Number of Individuals Covered	0
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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	0
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?	Yes
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

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

786-80081

Policy instance

Insurance contract or identification number	786-80081
Number of Individuals Covered	7
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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	0
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?	Yes
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

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

786-80081

Policy instance

Insurance contract or identification number	786-80081
Number of Individuals Covered	6
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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	0
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?	Yes
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

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

786-80081

Policy instance

Insurance contract or identification number	786-80081
Number of Individuals Covered	6
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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	0
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?	Yes
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:	BLUE MOUNTAIN HOSPITAL
Employer identification number (EIN):	200743054
NAIC Classification:	622000
NAIC Description:	Hospitals