401k Plan data: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN plan

NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 401k Plan overview

Plan Name	NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN
Plan identification number	505

NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Long-term disability cover Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20. Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

NORTH CENTRAL BEHAVIORAL HEALTH SYSTEMS, INC. has sponsored the creation of one or more 401k plans.

Company Name: NORTH CENTRAL BEHAVIORAL HEALTH SYSTEMS, INC.

Employer identification number (EIN): 362645920

NAIC Classification: 621420
NAIC Description: Outpatient Mental Health and Substance Abuse Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2014-01-01 LARRY BLOCK
505 2013-01-01 LARRY BLOCK
505 2011-01-01 LARRY BLOCK
505 2010-01-01 LARRY BLOCK
505 2009-01-01 LARRY BLOCK

Plan id#	Filing Submission Date	Name of Administrator
505	2014-01-01	LARRY BLOCK
505	2013-01-01	LARRY BLOCK
505	2011-01-01	LARRY BLOCK
505	2010-01-01	LARRY BLOCK
505	2009-01-01	LARRY BLOCK

Plan Statistics for NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN

401k plan membership statisitcs for NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN

Measure Date Value
2014: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY 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 89
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 0
Total of all active and inactive participants 2014-01-01 89
2013: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 102
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 99
Number of retired or separated participants receiving benefits 2013-01-01 1
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 100
2011: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 101
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 95
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 95
2010: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 99
Number of retired or separated participants receiving benefits 2010-01-01 2
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 101
2009: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 125
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 125

Measure	Date	Value
2014: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY 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	89
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	0
Total of all active and inactive participants	2014-01-01	89
2013: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	102
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	99
Number of retired or separated participants receiving benefits	2013-01-01	1
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	100
2011: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	101
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	95
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	95
2010: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	99
Number of retired or separated participants receiving benefits	2010-01-01	2
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	101
2009: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	125
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	125

Form 5500 Responses for NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN

2014: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY 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 – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY 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 – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2011: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: NORTH CENTRAL BEHAVIORAL SYSTEMS LONG-TERM DISABILITY PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

599582

Policy instance

Insurance contract or identification number	599582
Number of Individuals Covered	93
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,479
Total amount of fees paid to insurance company	USD $117
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?	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	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $24,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,479
Amount paid for insurance broker fees	117
Additional information about fees paid to insurance broker	VOLUME INCENTIVES
Insurance broker organization code?	3
Insurance broker name	DAKOTA STREET INSURANCE LLC

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

599582

Policy instance

Insurance contract or identification number	599582
Number of Individuals Covered	99
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,763
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?	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	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $25,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,511
Insurance broker organization code?	3
Insurance broker name	DAKOTA STREET INSURANCE LLC

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F1D0285

Policy instance

Insurance contract or identification number	F1D0285
Number of Individuals Covered	103
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,126
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?	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	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $26,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F1D0285

Policy instance

Insurance contract or identification number	F1D0285
Number of Individuals Covered	99
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,101
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?	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	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $27,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,101
Insurance broker organization code?	3
Insurance broker name	DAKOTA STREET INS, LLC

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Company Name:	NORTH CENTRAL BEHAVIORAL HEALTH SYSTEMS, INC.
Employer identification number (EIN):	362645920
NAIC Classification:	621420
NAIC Description:	Outpatient Mental Health and Substance Abuse Centers