401k Plan data: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN plan

AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 401k Plan overview

Plan Name	AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN
Plan identification number	503

AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision)

401k Sponsoring company profile

AMERISURE MUTUAL INSURANCE COMPANY 401K SAVINGS PLAN has sponsored the creation of one or more 401k plans.

Company Name: AMERISURE MUTUAL INSURANCE COMPANY 401K SAVINGS PLAN

Employer identification number (EIN): 380829210

NAIC Classification: 524150

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2016-01-01 ANGELA MCBRIDE
503 2015-01-01 ANGELA MCBRIDE
503 2014-01-01 ANGELA MCBRIDE
503 2013-01-01 ANGELA MCBRIDE
503 2012-01-01 ANGELA MCBRIDE
503 2011-01-01 ANGELA MCBRIDE

Plan id#	Filing Submission Date	Name of Administrator
503	2016-01-01	ANGELA MCBRIDE
503	2015-01-01	ANGELA MCBRIDE
503	2014-01-01	ANGELA MCBRIDE
503	2013-01-01	ANGELA MCBRIDE
503	2012-01-01	ANGELA MCBRIDE
503	2011-01-01	ANGELA MCBRIDE

Plan Statistics for AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN

401k plan membership statisitcs for AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN

Measure Date Value
2016: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 4
Number of retired or separated participants receiving benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
Total participants 2016-01-01 0
2015: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 5
Number of retired or separated participants receiving benefits 2015-01-01 4
Total of all active and inactive participants 2015-01-01 4
Total participants 2015-01-01 4
2014: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 8
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 0
Number of retired or separated participants receiving benefits 2014-01-01 5
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 5
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 5
2013: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 10
Number of retired or separated participants receiving benefits 2013-01-01 8
Total of all active and inactive participants 2013-01-01 8
Total participants 2013-01-01 8
2012: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 13
Number of retired or separated participants receiving benefits 2012-01-01 10
Total of all active and inactive participants 2012-01-01 10
Total participants 2012-01-01 10
2011: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 14
Number of retired or separated participants receiving benefits 2011-01-01 13
Total of all active and inactive participants 2011-01-01 13
Total participants 2011-01-01 13

Measure	Date	Value
2016: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	4
Number of retired or separated participants receiving benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
Total participants	2016-01-01	0
2015: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	5
Number of retired or separated participants receiving benefits	2015-01-01	4
Total of all active and inactive participants	2015-01-01	4
Total participants	2015-01-01	4
2014: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	8
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	0
Number of retired or separated participants receiving benefits	2014-01-01	5
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	5
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	5
2013: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	10
Number of retired or separated participants receiving benefits	2013-01-01	8
Total of all active and inactive participants	2013-01-01	8
Total participants	2013-01-01	8
2012: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	13
Number of retired or separated participants receiving benefits	2012-01-01	10
Total of all active and inactive participants	2012-01-01	10
Total participants	2012-01-01	10
2011: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	14
Number of retired or separated participants receiving benefits	2011-01-01	13
Total of all active and inactive participants	2011-01-01	13
Total participants	2011-01-01	13

Form 5500 Responses for AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN

2016: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	Yes
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 – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL 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 funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL 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 funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL PLAN 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 – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: AMERISURE MUTUAL INSURANCE COMPANY LONG TERM DISABILITY MEDICAL 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 funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

003324900

Policy instance

Insurance contract or identification number	003324900
Number of Individuals Covered	14
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Health Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $2,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name

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Company Name:	AMERISURE MUTUAL INSURANCE COMPANY 401K SAVINGS PLAN
Employer identification number (EIN):	380829210
NAIC Classification:	524150