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| Plan Name | ONE PEDIATRICS BENEFIT PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | ONE PEDIATRICS LLC |
| Employer identification number (EIN): | 300774617 |
| NAIC Classification: | 621111 |
| NAIC Description: | Offices of Physicians (except Mental Health Specialists) |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2020-01-01 | SUSAN DAMRON | 2021-07-16 | ||
| 501 | 2019-01-01 | MELISSA FORD | 2020-05-08 | ||
| 501 | 2017-01-01 | ||||
| 501 | 2016-01-01 | DR. STEPHEN CHURCH |
| 2020: ONE PEDIATRICS BENEFIT PLAN 2020 form 5500 responses | ||
|---|---|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: ONE PEDIATRICS BENEFIT PLAN 2019 form 5500 responses | ||
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: ONE PEDIATRICS BENEFIT PLAN 2017 form 5500 responses | ||
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: ONE PEDIATRICS BENEFIT PLAN 2016 form 5500 responses | ||
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | First time form 5500 has been submitted | Yes |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 ) | |
| Policy contract number | 789807 |
| Policy instance | 1 |
| HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 ) | |
| Policy contract number | 789807 |
| Policy instance | 1 |
| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) | |
| Policy contract number | 00246971 |
| Policy instance | 1 |
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