401k Plan data: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN plan

ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 401k Plan overview

Plan Name	ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN
Plan identification number	501

ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Dental Long-term disability cover

401k Sponsoring company profile

BLESSING CARE CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: BLESSING CARE CORPORATION

Employer identification number (EIN): 371396010

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-01-01 KATHY HULL
501 2016-01-01 KATHY HULL
501 2015-01-01 KATHY HULL
501 2014-01-01 KATHY HULL
501 2013-01-01 KATHY HULL
501 2012-01-01 KATHY HULL
501 2011-01-01 KATHY HULL
501 2009-01-01 CONNIE SCHROEDER

Plan id#	Filing Submission Date	Name of Administrator
501	2016-01-01	KATHY HULL
501	2016-01-01	KATHY HULL
501	2015-01-01	KATHY HULL
501	2014-01-01	KATHY HULL
501	2013-01-01	KATHY HULL
501	2012-01-01	KATHY HULL
501	2011-01-01	KATHY HULL
501	2009-01-01	CONNIE SCHROEDER

Plan Statistics for ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN

401k plan membership statisitcs for ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN

Measure Date Value
2016: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 37
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 34
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 3
Total of all active and inactive participants 2016-01-01 37
2015: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 43
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 37
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 0
Total of all active and inactive participants 2015-01-01 37
2014: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 45
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 43
Total of all active and inactive participants 2014-01-01 43
Total participants 2014-01-01 0
2013: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 62
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 45
Total of all active and inactive participants 2013-01-01 45
Total participants 2013-01-01 0
2012: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 63
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 60
Number of retired or separated participants receiving benefits 2012-01-01 2
Total of all active and inactive participants 2012-01-01 62
Total participants 2012-01-01 0
2011: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 119
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 63
Total of all active and inactive participants 2011-01-01 63
Total participants 2011-01-01 63
2009: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 191
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 208
Number of retired or separated participants receiving benefits 2009-01-01 2
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 210

Measure	Date	Value
2016: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	37
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	34
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	3
Total of all active and inactive participants	2016-01-01	37
2015: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	43
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	37
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	0
Total of all active and inactive participants	2015-01-01	37
2014: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	45
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	43
Total of all active and inactive participants	2014-01-01	43
Total participants	2014-01-01	0
2013: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	62
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	45
Total of all active and inactive participants	2013-01-01	45
Total participants	2013-01-01	0
2012: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	63
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	60
Number of retired or separated participants receiving benefits	2012-01-01	2
Total of all active and inactive participants	2012-01-01	62
Total participants	2012-01-01	0
2011: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	119
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	63
Total of all active and inactive participants	2011-01-01	63
Total participants	2011-01-01	63
2009: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	191
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	208
Number of retired or separated participants receiving benefits	2009-01-01	2
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	210

Form 5500 Responses for ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN

2016: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	Yes
2016-01-01	This submission is the final filing	Yes
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: ILLINI COMMUNITY HOSPITAL EMPLOYEE WELFARE 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

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

502913

Policy instance

Insurance contract or identification number	502913
Number of Individuals Covered	37
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,362
Insurance broker name	J ANDREW DAVIS FINANCIAL SERVICES

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

502913

Policy instance

Insurance contract or identification number	502913
Number of Individuals Covered	43
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $3,540
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,540
Insurance broker organization code?	3
Insurance broker name	J. ANDREW DAVIS FINANCIAL SERV

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

502913

Policy instance

Insurance contract or identification number	502913
Number of Individuals Covered	45
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $3,608
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,608
Insurance broker organization code?	3
Insurance broker name	J. ANDREW DAVIS FINANCIAL SERV

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

502913

Policy instance

Insurance contract or identification number	502913
Number of Individuals Covered	60
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $4,065
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,065
Insurance broker organization code?	3
Insurance broker name	J. ANDREW DAVIS FINANCIAL SERV

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

502913

Policy instance

Insurance contract or identification number	502913
Number of Individuals Covered	63
Insurance policy start date	2011-01-01
Insurance policy end date	2012-01-01
Total amount of commissions paid to insurance broker	USD $3,845
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

10034

Policy instance

Insurance contract or identification number	10034
Number of Individuals Covered	119
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,365
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,365
Insurance broker organization code?	3
Insurance broker name	J. ANDREW DAVIS FINANCIAL SERV

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

502913

Policy instance

Insurance contract or identification number	502913
Number of Individuals Covered	71
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,253
Total amount of fees paid to insurance company	USD $338
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,253
Amount paid for insurance broker fees	338
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	J. ANDREW DAVIS FINANCIAL SERV

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Company Name:	BLESSING CARE CORPORATION
Employer identification number (EIN):	371396010
NAIC Classification:	622000
NAIC Description:	Hospitals