401k Plan data: BLACK RIVER MEDICAL CENTER 401(K) plan

BLACK RIVER MEDICAL CENTER 401(K) 401k Plan overview

Plan Name	BLACK RIVER MEDICAL CENTER 401(K)
Plan identification number	001

BLACK RIVER MEDICAL CENTER 401(K) 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 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
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

BLACK RIVER MEDICAL CENTER has sponsored the creation of one or more 401k plans.

Company Name: BLACK RIVER MEDICAL CENTER

Employer identification number (EIN): 273622460

NAIC Classification: 812990
NAIC Description: All Other Personal Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLACK RIVER MEDICAL CENTER 401(K)

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2020-01-01
001 2019-01-01
001 2018-01-01
001 2017-01-01
001 2016-01-01
001 2015-01-01 PHILIP CROCKER 2016-07-11 PHILIP CROCKER 2016-07-11
001 2014-01-01 PHILIP CROCKER PHILIP CROCKER 2015-07-23
001 2013-01-01 PHILIP CROCKER PHILIP CROCKER 2014-07-16
001 2012-01-01 DEBORA BOYER

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2020-01-01
001	2019-01-01
001	2018-01-01
001	2017-01-01
001	2016-01-01
001	2015-01-01	PHILIP CROCKER	2016-07-11	PHILIP CROCKER	2016-07-11
001	2014-01-01	PHILIP CROCKER		PHILIP CROCKER	2015-07-23
001	2013-01-01	PHILIP CROCKER		PHILIP CROCKER	2014-07-16
001	2012-01-01	DEBORA BOYER

Plan Statistics for BLACK RIVER MEDICAL CENTER 401(K)

401k plan membership statisitcs for BLACK RIVER MEDICAL CENTER 401(K)

Measure Date Value
2014: BLACK RIVER MEDICAL CENTER 401(K) 2014 401k membership
Total participants, beginning-of-year 2014-01-01 65
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 63
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 9
Total of all active and inactive participants 2014-01-01 72
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 72
Number of participants with account balances 2014-01-01 43
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 6
2013: BLACK RIVER MEDICAL CENTER 401(K) 2013 401k membership
Total participants, beginning-of-year 2013-01-01 72
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 70
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 13
Total of all active and inactive participants 2013-01-01 83
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 83
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 5
2012: BLACK RIVER MEDICAL CENTER 401(K) 2012 401k membership
Total participants, beginning-of-year 2012-01-01 54
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 49
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 12
Total of all active and inactive participants 2012-01-01 61
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 61
Number of participants with account balances 2012-01-01 49
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 10

Measure	Date	Value
2014: BLACK RIVER MEDICAL CENTER 401(K) 2014 401k membership
Total participants, beginning-of-year	2014-01-01	65
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	63
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	9
Total of all active and inactive participants	2014-01-01	72
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	72
Number of participants with account balances	2014-01-01	43
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	6
2013: BLACK RIVER MEDICAL CENTER 401(K) 2013 401k membership
Total participants, beginning-of-year	2013-01-01	72
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	70
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	13
Total of all active and inactive participants	2013-01-01	83
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	83
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	5
2012: BLACK RIVER MEDICAL CENTER 401(K) 2012 401k membership
Total participants, beginning-of-year	2012-01-01	54
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	49
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	12
Total of all active and inactive participants	2012-01-01	61
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	61
Number of participants with account balances	2012-01-01	49
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	10

Financial Data on BLACK RIVER MEDICAL CENTER 401(K)

Measure	Date	Value
2014 : BLACK RIVER MEDICAL CENTER 401(K) 2014 401k financial data
Transfers to/from the plan	2014-12-31	$1,309
Total income from all sources	2014-12-31	$297,401
Expenses. Total of all expenses incurred	2014-12-31	$134,869
Benefits paid (including direct rollovers)	2014-12-31	$112,674
Total plan assets at end of year	2014-12-31	$1,991,485
Total plan assets at beginning of year	2014-12-31	$1,827,644
Value of fidelity bond covering the plan	2014-12-31	$200,000
Total contributions received or receivable from participants	2014-12-31	$160,281
Expenses. Other expenses not covered elsewhere	2014-12-31	$236
Contributions received from other sources (not participants or employers)	2014-12-31	$0
Other income received	2014-12-31	$71,976
Net income (gross income less expenses)	2014-12-31	$162,532
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$1,991,485
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$1,827,644
Assets. Value of participant loans	2014-12-31	$28,329
Total contributions received or receivable from employer(s)	2014-12-31	$65,144
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$21,959
Funding deficiency by the employer to the plan for this plan year	2014-12-31	$0
Minimum employer required contribution for this plan year	2014-12-31	$0
Amount contributed by the employer to the plan for this plan year	2014-12-31	$0
2013 : BLACK RIVER MEDICAL CENTER 401(K) 2013 401k financial data
Transfers to/from the plan	2013-12-31	$0
Total income from all sources	2013-12-31	$495,005
Expenses. Total of all expenses incurred	2013-12-31	$21,941
Benefits paid (including direct rollovers)	2013-12-31	$18,523
Total plan assets at end of year	2013-12-31	$1,827,644
Total plan assets at beginning of year	2013-12-31	$1,354,580
Value of fidelity bond covering the plan	2013-12-31	$200,000
Total contributions received or receivable from participants	2013-12-31	$153,945
Expenses. Other expenses not covered elsewhere	2013-12-31	$125
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$288,362
Net income (gross income less expenses)	2013-12-31	$473,064
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$1,827,644
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$1,354,580
Assets. Value of participant loans	2013-12-31	$0
Total contributions received or receivable from employer(s)	2013-12-31	$52,698
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$3,293
Funding deficiency by the employer to the plan for this plan year	2013-12-31	$0
Minimum employer required contribution for this plan year	2013-12-31	$0
Amount contributed by the employer to the plan for this plan year	2013-12-31	$0
2012 : BLACK RIVER MEDICAL CENTER 401(K) 2012 401k financial data
Transfers to/from the plan	2012-12-31	$0
Total income from all sources	2012-12-31	$345,585
Expenses. Total of all expenses incurred	2012-12-31	$95,997
Benefits paid (including direct rollovers)	2012-12-31	$95,897
Total plan assets at end of year	2012-12-31	$1,354,580
Total plan assets at beginning of year	2012-12-31	$1,104,992
Value of fidelity bond covering the plan	2012-12-31	$200,000
Total contributions received or receivable from participants	2012-12-31	$130,917
Expenses. Other expenses not covered elsewhere	2012-12-31	$100
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$167,019
Net income (gross income less expenses)	2012-12-31	$249,588
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$1,354,580
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$1,104,992
Assets. Value of participant loans	2012-12-31	$0
Total contributions received or receivable from employer(s)	2012-12-31	$47,649
Value of certain deemed distributions of participant loans	2012-12-31	$0
Value of corrective distributions	2012-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2012-12-31	$0
Minimum employer required contribution for this plan year	2012-12-31	$0
Amount contributed by the employer to the plan for this plan year	2012-12-31	$0

Form 5500 Responses for BLACK RIVER MEDICAL CENTER 401(K)

2014: BLACK RIVER MEDICAL CENTER 401(K) 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 – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: BLACK RIVER MEDICAL CENTER 401(K) 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 – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: BLACK RIVER MEDICAL CENTER 401(K) 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-824404

Policy instance

Insurance contract or identification number	GA-824404
Number of Individuals Covered	43
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,256
Total amount of fees paid to insurance company	USD $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 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?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
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 $7,256
Insurance broker organization code?	3
Insurance broker name	SBHU LIFE AGENCY INC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-824404

Policy instance

Insurance contract or identification number	GA-824404
Number of Individuals Covered	40
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,819
Total amount of fees paid to insurance company	USD $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 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?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
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 $5,819
Insurance broker organization code?	3
Insurance broker name	SBHU LIFE AGCY INC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-824404

Policy instance

Insurance contract or identification number	GA-824404
Number of Individuals Covered	49
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,723
Total amount of fees paid to insurance company	USD $107
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 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?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
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 $3,723
Insurance broker organization code?	3
Amount paid for insurance broker fees	82
Additional information about fees paid to insurance broker	SALES/MARKETING
Insurance broker name	MORGANSTANLEY SMITHBARNEY LLC

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Company Name:	BLACK RIVER MEDICAL CENTER
Employer identification number (EIN):	273622460
NAIC Classification:	812990
NAIC Description:	All Other Personal Services