401k Plan data: LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST plan

LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 401k Plan overview

Plan Name	LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST
Plan identification number	001

LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 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

LIFECARE AMBULANCE, INC. has sponsored the creation of one or more 401k plans.

Company Name: LIFECARE AMBULANCE, INC.

Employer identification number (EIN): 341523694

NAIC Classification: 621900

Additional information about LIFECARE AMBULANCE, INC.

Jurisdiction of Incorporation: Colorado Department of State

Incorporation Date: 2003-10-06

Company Identification Number: 20031317250

Legal Registered Office Address: 2069 BLUEWATER DR

Fruita
United States of America (USA)
81521

More information about LIFECARE AMBULANCE, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01 KIMBERLY MASON 2023-10-04
001 2021-01-01 KIMBERLY MASON 2022-10-16
001 2020-01-01 DAVID RICHARDS 2021-10-08
001 2019-01-01 DAVID RICHARDS 2020-10-12
001 2018-01-01 DAVID RICHARDS 2019-10-11
001 2017-01-01 HERBERT ANDRE DE LA PORTE 2018-10-15
001 2016-01-01 PETER DE LA PORTE 2017-10-12
001 2015-01-01 PETER DE LA PORTE 2016-10-13
001 2014-01-01 PETER DE LA PORTE
001 2014-01-01 PETER DE LA PORTE
001 2013-01-01 PETER DE LA PORTE
001 2012-01-01 PETER DE LA PORTE

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2022-01-01	KIMBERLY MASON	2023-10-04
001	2021-01-01	KIMBERLY MASON	2022-10-16
001	2020-01-01	DAVID RICHARDS	2021-10-08
001	2019-01-01	DAVID RICHARDS	2020-10-12
001	2018-01-01	DAVID RICHARDS	2019-10-11
001	2017-01-01	HERBERT ANDRE DE LA PORTE	2018-10-15
001	2016-01-01	PETER DE LA PORTE	2017-10-12
001	2015-01-01	PETER DE LA PORTE	2016-10-13
001	2014-01-01	PETER DE LA PORTE
001	2014-01-01	PETER DE LA PORTE
001	2013-01-01	PETER DE LA PORTE
001	2012-01-01	PETER DE LA PORTE

Plan Statistics for LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST

401k plan membership statisitcs for LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST

Measure Date Value
2014: LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 2014 401k membership
Total participants, beginning-of-year 2014-01-01 216
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 52
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 38
Total of all active and inactive participants 2014-01-01 90
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 90
Number of participants with account balances 2014-01-01 90
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 2013 401k membership
Total participants, beginning-of-year 2013-01-01 232
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 170
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 46
Total of all active and inactive participants 2013-01-01 216
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 216
Number of participants with account balances 2013-01-01 101
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 2
2012: LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 2012 401k membership
Total participants, beginning-of-year 2012-01-01 183
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 123
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 46
Total of all active and inactive participants 2012-01-01 169
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 169
Number of participants with account balances 2012-01-01 109
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 5

Measure	Date	Value
2014: LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 2014 401k membership
Total participants, beginning-of-year	2014-01-01	216
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	52
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	38
Total of all active and inactive participants	2014-01-01	90
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	90
Number of participants with account balances	2014-01-01	90
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 2013 401k membership
Total participants, beginning-of-year	2013-01-01	232
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	170
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	46
Total of all active and inactive participants	2013-01-01	216
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	216
Number of participants with account balances	2013-01-01	101
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	2
2012: LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 2012 401k membership
Total participants, beginning-of-year	2012-01-01	183
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	123
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	46
Total of all active and inactive participants	2012-01-01	169
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	169
Number of participants with account balances	2012-01-01	109
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	5

Financial Data on LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST

Measure	Date	Value
2014 : LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 2014 401k financial data
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total income from all sources (including contributions)	2014-12-31	$191,696
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$58,608
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$46,116
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$123,040
Value of total assets at end of year	2014-12-31	$1,858,148
Value of total assets at beginning of year	2014-12-31	$1,725,060
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$12,492
Total interest from all sources	2014-12-31	$637
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Administrative expenses professional fees incurred	2014-12-31	$875
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$140,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$56,111
Participant contributions at end of year	2014-12-31	$13,989
Participant contributions at beginning of year	2014-12-31	$2,830
Income. Received or receivable in cash from other sources (including rollovers)	2014-12-31	$43,527
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$133,088
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$1,858,148
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$1,725,060
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest in pooled separate accounts at end of year	2014-12-31	$1,519,325
Value of interest in pooled separate accounts at beginning of year	2014-12-31	$1,445,004
Interest on participant loans	2014-12-31	$637
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2014-12-31	$47,879
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2014-12-31	$460
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2014-12-31	$460
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$276,955
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$276,766
Net investment gain/loss from pooled separate accounts	2014-12-31	$68,019
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	No
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$23,402
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$46,116
Contract administrator fees	2014-12-31	$11,617
Did the plan have assets held for investment	2014-12-31	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	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	MALONEY NOVOTNY, LLC
Accountancy firm EIN	2014-12-31	340677006
2013 : LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 2013 401k financial data
Total unrealized appreciation/depreciation of assets	2013-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total income from all sources (including contributions)	2013-12-31	$276,051
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$76,088
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$64,474
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$82,986
Value of total assets at end of year	2013-12-31	$1,725,060
Value of total assets at beginning of year	2013-12-31	$1,525,097
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$11,614
Total interest from all sources	2013-12-31	$172
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-12-31	No
Administrative expenses professional fees incurred	2013-12-31	$475
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$140,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$58,794
Participant contributions at end of year	2013-12-31	$2,830
Participant contributions at beginning of year	2013-12-31	$5,322
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$199,963
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$1,725,060
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$1,525,097
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Value of interest in pooled separate accounts at end of year	2013-12-31	$1,445,004
Value of interest in pooled separate accounts at beginning of year	2013-12-31	$1,297,407
Income. Interest from loans (other than to participants)	2013-12-31	$172
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2013-12-31	$460
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2013-12-31	$20
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2013-12-31	$20
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$276,766
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$222,348
Net investment gain/loss from pooled separate accounts	2013-12-31	$192,893
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	No
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Contributions received in cash from employer	2013-12-31	$24,192
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$64,474
Contract administrator fees	2013-12-31	$11,139
Did the plan have assets held for investment	2013-12-31	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	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2013-12-31	Disclaimer
Accountancy firm name	2013-12-31	MALONEY NOVOTNY, LLC
Accountancy firm EIN	2013-12-31	340677006
2012 : LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 2012 401k financial data
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total income from all sources (including contributions)	2012-12-31	$250,184
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$81,920
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$70,859
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$91,599
Value of total assets at end of year	2012-12-31	$1,525,097
Value of total assets at beginning of year	2012-12-31	$1,356,833
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$11,061
Total interest from all sources	2012-12-31	$274
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Administrative expenses professional fees incurred	2012-12-31	$500
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$140,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$63,225
Participant contributions at end of year	2012-12-31	$5,322
Participant contributions at beginning of year	2012-12-31	$7,712
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$4,401
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$168,264
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$1,525,097
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$1,356,833
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest in pooled separate accounts at end of year	2012-12-31	$1,297,407
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$1,136,339
Interest on participant loans	2012-12-31	$274
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-12-31	$20
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-12-31	$793
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-12-31	$793
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$222,348
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$211,989
Net investment gain/loss from pooled separate accounts	2012-12-31	$158,311
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$23,973
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$70,859
Contract administrator fees	2012-12-31	$10,561
Did the plan have assets held for investment	2012-12-31	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	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	MALONEY NOVOTNY, LLC
Accountancy firm EIN	2012-12-31	340677006

Form 5500 Responses for LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST

2014: LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
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
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 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
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: LIFECARE AMBULANCE, INC. THIRD AMENDED AND RESTATED 401(K) PROFIT-SHARING PLAN AND TRUST 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
2012-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

29684

Policy instance

Insurance contract or identification number	29684
Number of Individuals Covered	100
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,438
Total amount of fees paid to insurance company	USD $4,945
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 $0
Amount paid for insurance broker fees	4920
Additional information about fees paid to insurance broker	TPA ADMINISTRATION
Insurance broker organization code?	5
Insurance broker name	INTEGRATED RETIREMENT PLAN SOLUTION

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

29684

Policy instance

Insurance contract or identification number	29684
Number of Individuals Covered	108
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,013
Total amount of fees paid to insurance company	USD $663
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
Commission paid to Insurance Broker	USD $4,013
Insurance broker organization code?	3
Amount paid for insurance broker fees	663
Additional information about fees paid to insurance broker	TPA ADMINISTRATION AND TPA FORUM COMPENSATION
Insurance broker name	FRANCIS P. GALLAGHER & ASSOC., INC

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

29684

Policy instance

Insurance contract or identification number	29684
Number of Individuals Covered	111
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,629
Total amount of fees paid to insurance company	USD $1,215
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
Commission paid to Insurance Broker	USD $3,629
Insurance broker organization code?	3
Amount paid for insurance broker fees	1215
Additional information about fees paid to insurance broker	TPA ADMINISTRATION AND TPA FORUM COMPENSATION
Insurance broker name	FRANCIS P. GALLAGHER & ASSOC., INC

Potentially related plans

LIFECARE AMBULANCE, INC. 401(K) RETIREMENT PLAN [EIN = 341565037]

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Company Name:	LIFECARE AMBULANCE, INC.
Employer identification number (EIN):	341523694
NAIC Classification:	621900

Jurisdiction of Incorporation:	Colorado Department of State
Incorporation Date:	2003-10-06
Company Identification Number:	20031317250
Legal Registered Office Address:	2069 BLUEWATER DR Fruita United States of America (USA) 81521