401k Plan data: MADELIA COMMUNITY HOSPITAL 403(B) PLAN plan

MADELIA COMMUNITY HOSPITAL 403(B) PLAN 401k Plan overview

Plan Name	MADELIA COMMUNITY HOSPITAL 403(B) PLAN
Plan identification number	002

MADELIA COMMUNITY HOSPITAL 403(B) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
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.
Code section 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.
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

MADELIA COMMUNITY HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name: MADELIA COMMUNITY HOSPITAL

Employer identification number (EIN): 410758512

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MADELIA COMMUNITY HOSPITAL 403(B) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2022-01-01 JORDAN RICHARDSON 2023-10-09
002 2021-01-01 JORDAN RICHARDSON 2022-10-17
002 2020-01-01 JORDAN RICHARDSON 2021-10-12
002 2020-01-01 JORDAN RICHARDSON 2022-09-29
002 2019-01-01 JEFF MENGENHAUSEN 2020-10-08
002 2018-01-01 JEFF MENGENHAUSEN 2019-10-07
002 2017-01-01
002 2016-01-01
002 2015-01-01
002 2014-01-01
002 2013-01-01 DONNA KLINKNER

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
002	2022-01-01	JORDAN RICHARDSON	2023-10-09
002	2021-01-01	JORDAN RICHARDSON	2022-10-17
002	2020-01-01	JORDAN RICHARDSON	2021-10-12
002	2020-01-01	JORDAN RICHARDSON	2022-09-29
002	2019-01-01	JEFF MENGENHAUSEN	2020-10-08
002	2018-01-01	JEFF MENGENHAUSEN	2019-10-07
002	2017-01-01
002	2016-01-01
002	2015-01-01
002	2014-01-01
002	2013-01-01	DONNA KLINKNER

Plan Statistics for MADELIA COMMUNITY HOSPITAL 403(B) PLAN

401k plan membership statisitcs for MADELIA COMMUNITY HOSPITAL 403(B) PLAN

Measure Date Value
2022: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 199
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 169
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 47
Total of all active and inactive participants 2022-01-01 216
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 216
Number of participants with account balances 2022-01-01 142
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 6
2021: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 178
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 161
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 38
Total of all active and inactive participants 2021-01-01 199
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 199
Number of participants with account balances 2021-01-01 131
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 4
2020: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 146
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 136
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 42
Total of all active and inactive participants 2020-01-01 178
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 178
Number of participants with account balances 2020-01-01 108
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 1
2019: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 134
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 107
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 39
Total of all active and inactive participants 2019-01-01 146
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 146
Number of participants with account balances 2019-01-01 105
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 1
2018: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 131
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 108
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 26
Total of all active and inactive participants 2018-01-01 134
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 134
Number of participants with account balances 2018-01-01 103
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 2
2017: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 111
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 20
Total of all active and inactive participants 2017-01-01 131
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 131
Number of participants with account balances 2017-01-01 98
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 126
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 114
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 19
Total of all active and inactive participants 2016-01-01 133
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 133
Number of participants with account balances 2016-01-01 95
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 117
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 111
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 15
Total of all active and inactive participants 2015-01-01 126
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 126
Number of participants with account balances 2015-01-01 85
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 1
2014: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 114
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 104
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 13
Total of all active and inactive participants 2014-01-01 117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 117
Number of participants with account balances 2014-01-01 82
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 1
2013: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 100
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 14
Total of all active and inactive participants 2013-01-01 114
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 114
Number of participants with account balances 2013-01-01 86
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0

Measure	Date	Value
2022: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	199
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	169
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	47
Total of all active and inactive participants	2022-01-01	216
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	216
Number of participants with account balances	2022-01-01	142
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	6
2021: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	178
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	161
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	38
Total of all active and inactive participants	2021-01-01	199
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	199
Number of participants with account balances	2021-01-01	131
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	4
2020: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	146
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	136
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	42
Total of all active and inactive participants	2020-01-01	178
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	178
Number of participants with account balances	2020-01-01	108
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	1
2019: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	134
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	107
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	39
Total of all active and inactive participants	2019-01-01	146
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	146
Number of participants with account balances	2019-01-01	105
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	1
2018: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	131
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	108
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	26
Total of all active and inactive participants	2018-01-01	134
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	134
Number of participants with account balances	2018-01-01	103
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	2
2017: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	111
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	20
Total of all active and inactive participants	2017-01-01	131
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	131
Number of participants with account balances	2017-01-01	98
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	126
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	114
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	19
Total of all active and inactive participants	2016-01-01	133
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	133
Number of participants with account balances	2016-01-01	95
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	117
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	111
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	15
Total of all active and inactive participants	2015-01-01	126
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	126
Number of participants with account balances	2015-01-01	85
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	1
2014: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	104
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	13
Total of all active and inactive participants	2014-01-01	117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	117
Number of participants with account balances	2014-01-01	82
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	1
2013: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	100
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	14
Total of all active and inactive participants	2013-01-01	114
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	114
Number of participants with account balances	2013-01-01	86
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0

Financial Data on MADELIA COMMUNITY HOSPITAL 403(B) PLAN

Measure	Date	Value
2022 : MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$-202,501
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$160,470
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$127,758
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$833,437
Value of total assets at end of year	2022-12-31	$7,336,044
Value of total assets at beginning of year	2022-12-31	$7,699,015
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$32,712
Total interest from all sources	2022-12-31	$3,462
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$666,760
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2022-12-31	$666,760
Administrative expenses professional fees incurred	2022-12-31	$32,712
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$500,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$515,118
Participant contributions at end of year	2022-12-31	$70,286
Participant contributions at beginning of year	2022-12-31	$52,978
Participant contributions at end of year	2022-12-31	$17,415
Participant contributions at beginning of year	2022-12-31	$16,249
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$43,110
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-362,971
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$7,336,044
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$7,699,015
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$5,639,082
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$6,108,521
Interest on participant loans	2022-12-31	$3,462
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$1,598,353
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$1,512,477
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-1,706,160
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$275,209
Employer contributions (assets) at end of year	2022-12-31	$10,908
Employer contributions (assets) at beginning of year	2022-12-31	$8,790
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$127,758
Did the plan have assets held for investment	2022-12-31	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	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	EIDE BAILLY, LLP
Accountancy firm EIN	2022-12-31	450250958
2021 : MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$1,671,596
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$855,783
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$821,738
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$666,469
Value of total assets at end of year	2021-12-31	$7,699,015
Value of total assets at beginning of year	2021-12-31	$6,883,202
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$34,045
Total interest from all sources	2021-12-31	$2,658
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$559,177
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2021-12-31	$559,177
Administrative expenses professional fees incurred	2021-12-31	$34,045
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$429,796
Participant contributions at end of year	2021-12-31	$52,978
Participant contributions at beginning of year	2021-12-31	$75,195
Participant contributions at end of year	2021-12-31	$16,249
Participant contributions at beginning of year	2021-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$24,589
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$815,813
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$7,699,015
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$6,883,202
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$6,108,521
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$5,243,535
Interest on participant loans	2021-12-31	$2,658
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$1,512,477
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$1,564,472
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$443,292
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$212,084
Employer contributions (assets) at end of year	2021-12-31	$8,790
Employer contributions (assets) at beginning of year	2021-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$821,738
Did the plan have assets held for investment	2021-12-31	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	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	EIDE BAILLY, LLP
Accountancy firm EIN	2021-12-31	450250958
2020 : MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$1,569,161
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$1,704,358
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$1,673,029
Expenses. Certain deemed distributions of participant loans	2020-12-31	$2,609
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$608,262
Value of total assets at end of year	2020-12-31	$6,911,224
Value of total assets at beginning of year	2020-12-31	$7,046,421
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$28,720
Total interest from all sources	2020-12-31	$3,923
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$630,956
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2020-12-31	$630,956
Administrative expenses professional fees incurred	2020-12-31	$28,720
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2020-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$279,005
Participant contributions at end of year	2020-12-31	$75,195
Participant contributions at beginning of year	2020-12-31	$102,753
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$168,559
Assets. Loans (other than to participants) at end of year	2020-12-31	$97,905
Assets. Loans (other than to participants) at beginning of year	2020-12-31	$102,753
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$-135,197
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$6,911,224
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$7,046,421
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$5,243,535
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$5,082,165
Value of interest in pooled separate accounts at end of year	2020-12-31	$0
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$0
Interest on participant loans	2020-12-31	$3,923
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$1,569,784
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-12-31	$1,861,503
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$326,020
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$160,698
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$1,673,029
Did the plan have assets held for investment	2020-12-31	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	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Disclaimer
Accountancy firm name	2020-12-31	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2020-12-31	410746749
2019 : MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$1,715,496
Total income from all sources (including contributions)	2019-12-31	$1,715,496
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$2,502,830
Total of all expenses incurred	2019-12-31	$2,502,830
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$2,474,278
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$2,474,278
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$474,736
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$474,736
Value of total assets at end of year	2019-12-31	$7,046,421
Value of total assets at end of year	2019-12-31	$7,046,421
Value of total assets at beginning of year	2019-12-31	$7,833,755
Value of total assets at beginning of year	2019-12-31	$7,833,755
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$28,552
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$28,552
Total interest from all sources	2019-12-31	$2,688
Total interest from all sources	2019-12-31	$2,688
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$1,238,072
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$1,238,072
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2019-12-31	$1,238,072
Total dividends received from registered investment company shares (eg mutual funds)	2019-12-31	$1,238,072
Administrative expenses professional fees incurred	2019-12-31	$28,552
Administrative expenses professional fees incurred	2019-12-31	$28,552
Was this plan covered by a fidelity bond	2019-12-31	Yes
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$1,000,000
Value of fidelity bond cover	2019-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2019-12-31	No
If this is an individual account plan, was there a blackout period	2019-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$306,192
Contributions received from participants	2019-12-31	$306,192
Assets. Loans (other than to participants) at end of year	2019-12-31	$102,753
Assets. Loans (other than to participants) at end of year	2019-12-31	$102,753
Assets. Loans (other than to participants) at beginning of year	2019-12-31	$72,857
Assets. Loans (other than to participants) at beginning of year	2019-12-31	$72,857
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$-787,334
Value of net income/loss	2019-12-31	$-787,334
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$7,046,421
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$7,046,421
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$7,833,755
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$5,082,165
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$5,082,165
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$0
Value of interest in pooled separate accounts at end of year	2019-12-31	$0
Value of interest in pooled separate accounts at end of year	2019-12-31	$0
Value of interest in pooled separate accounts at beginning of year	2019-12-31	$7,760,898
Value of interest in pooled separate accounts at beginning of year	2019-12-31	$7,760,898
Interest on participant loans	2019-12-31	$2,688
Interest on participant loans	2019-12-31	$2,688
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$1,861,503
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$1,861,503
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Contributions received in cash from employer	2019-12-31	$168,544
Contributions received in cash from employer	2019-12-31	$168,544
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$2,474,278
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$2,474,278
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan have assets held for investment	2019-12-31	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	2019-12-31	No
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	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2019-12-31	410746749
Accountancy firm EIN	2019-12-31	410746749
2018 : MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2018 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2018-12-31	$-205,307
Total unrealized appreciation/depreciation of assets	2018-12-31	$-205,307
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total income from all sources (including contributions)	2018-12-31	$284,869
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$119,663
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$119,085
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$488,358
Value of total assets at end of year	2018-12-31	$7,833,755
Value of total assets at beginning of year	2018-12-31	$7,668,549
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$578
Total interest from all sources	2018-12-31	$1,818
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Administrative expenses professional fees incurred	2018-12-31	$578
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$500,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$309,895
Income. Received or receivable in cash from other sources (including rollovers)	2018-12-31	$2,736
Assets. Loans (other than to participants) at end of year	2018-12-31	$72,857
Assets. Loans (other than to participants) at beginning of year	2018-12-31	$46,902
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$165,206
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$7,833,755
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$7,668,549
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Value of interest in pooled separate accounts at end of year	2018-12-31	$7,760,898
Value of interest in pooled separate accounts at beginning of year	2018-12-31	$7,621,647
Interest on participant loans	2018-12-31	$1,818
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Contributions received in cash from employer	2018-12-31	$175,727
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$119,085
Did the plan have assets held for investment	2018-12-31	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	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2018-12-31	410746749
2017 : MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2017 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2017-12-31	$775,233
Total unrealized appreciation/depreciation of assets	2017-12-31	$775,233
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total income from all sources (including contributions)	2017-12-31	$1,282,877
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$215,309
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$189,359
Expenses. Certain deemed distributions of participant loans	2017-12-31	$25,278
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$505,412
Value of total assets at end of year	2017-12-31	$7,668,549
Value of total assets at beginning of year	2017-12-31	$6,600,981
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$672
Total interest from all sources	2017-12-31	$2,232
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Administrative expenses professional fees incurred	2017-12-31	$672
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$500,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$295,610
Income. Received or receivable in cash from other sources (including rollovers)	2017-12-31	$41,174
Assets. Loans (other than to participants) at end of year	2017-12-31	$46,902
Assets. Loans (other than to participants) at beginning of year	2017-12-31	$81,244
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$1,067,568
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$7,668,549
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$6,600,981
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Value of interest in pooled separate accounts at end of year	2017-12-31	$7,621,647
Value of interest in pooled separate accounts at beginning of year	2017-12-31	$6,519,737
Interest on participant loans	2017-12-31	$2,232
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	No
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Contributions received in cash from employer	2017-12-31	$168,628
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$189,359
Did the plan have assets held for investment	2017-12-31	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	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2017-12-31	410746749
2016 : MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2016 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2016-12-31	$353,234
Total unrealized appreciation/depreciation of assets	2016-12-31	$353,234
Total transfer of assets to this plan	2016-12-31	$0
Total income from all sources (including contributions)	2016-12-31	$894,267
Total of all expenses incurred	2016-12-31	$220,820
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$216,190
Expenses. Certain deemed distributions of participant loans	2016-12-31	$4,630
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$538,753
Value of total assets at end of year	2016-12-31	$6,600,981
Value of total assets at beginning of year	2016-12-31	$5,927,534
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$0
Total interest from all sources	2016-12-31	$2,280
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$500,000
If this is an individual account plan, was there a blackout period	2016-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$308,556
Income. Received or receivable in cash from other sources (including rollovers)	2016-12-31	$62,287
Assets. Loans (other than to participants) at end of year	2016-12-31	$81,244
Assets. Loans (other than to participants) at beginning of year	2016-12-31	$77,080
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Value of net income/loss	2016-12-31	$673,447
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$6,600,981
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$5,927,534
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest in pooled separate accounts at end of year	2016-12-31	$6,519,737
Value of interest in pooled separate accounts at beginning of year	2016-12-31	$5,850,454
Interest on participant loans	2016-12-31	$2,280
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	No
Was there a failure to transmit to the plan any participant contributions	2016-12-31	No
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Contributions received in cash from employer	2016-12-31	$167,910
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$216,190
Did the plan have assets held for investment	2016-12-31	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	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2016-12-31	Disclaimer
Accountancy firm name	2016-12-31	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2016-12-31	410746749
2015 : MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2015 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2015-12-31	$11,924
Total unrealized appreciation/depreciation of assets	2015-12-31	$11,924
Total income from all sources (including contributions)	2015-12-31	$575,693
Total of all expenses incurred	2015-12-31	$154,706
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$130,618
Expenses. Certain deemed distributions of participant loans	2015-12-31	$24,088
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$561,424
Value of total assets at end of year	2015-12-31	$5,927,534
Value of total assets at beginning of year	2015-12-31	$5,506,547
Total interest from all sources	2015-12-31	$2,345
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$200,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$289,856
Income. Received or receivable in cash from other sources (including rollovers)	2015-12-31	$112,238
Assets. Loans (other than to participants) at end of year	2015-12-31	$77,080
Assets. Loans (other than to participants) at beginning of year	2015-12-31	$73,453
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$420,987
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$5,927,534
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$5,506,547
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest in pooled separate accounts at end of year	2015-12-31	$5,850,454
Value of interest in pooled separate accounts at beginning of year	2015-12-31	$5,433,094
Income. Interest from loans (other than to participants)	2015-12-31	$2,345
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	No
Was there a failure to transmit to the plan any participant contributions	2015-12-31	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$159,330
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$130,618
Did the plan have assets held for investment	2015-12-31	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	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2015-12-31	410746749
2014 : MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2014 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2014-12-31	$175,380
Total unrealized appreciation/depreciation of assets	2014-12-31	$175,380
Total income from all sources (including contributions)	2014-12-31	$886,051
Total of all expenses incurred	2014-12-31	$223,597
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$213,207
Expenses. Certain deemed distributions of participant loans	2014-12-31	$10,390
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$706,797
Value of total assets at end of year	2014-12-31	$5,506,547
Value of total assets at beginning of year	2014-12-31	$4,844,093
Total interest from all sources	2014-12-31	$3,874
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$283,612
Income. Received or receivable in cash from other sources (including rollovers)	2014-12-31	$270,134
Assets. Loans (other than to participants) at end of year	2014-12-31	$73,453
Assets. Loans (other than to participants) at beginning of year	2014-12-31	$100,887
Total non interest bearing cash at beginning of year	2014-12-31	$755
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	$662,454
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$5,506,547
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$4,844,093
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	$5,433,094
Value of interest in pooled separate accounts at beginning of year	2014-12-31	$4,742,451
Interest on participant loans	2014-12-31	$3,874
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	$153,051
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$213,207
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	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2014-12-31	410746749
2013 : MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2013 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2013-12-31	$532,714
Total unrealized appreciation/depreciation of assets	2013-12-31	$532,714
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	$949,561
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$169,918
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$132,677
Expenses. Certain deemed distributions of participant loans	2013-12-31	$37,241
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$414,667
Value of total assets at end of year	2013-12-31	$4,844,093
Value of total assets at beginning of year	2013-12-31	$4,064,450
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$0
Total interest from all sources	2013-12-31	$2,180
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
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$270,627
Participant contributions at end of year	2013-12-31	$100,887
Participant contributions at beginning of year	2013-12-31	$31,145
Total non interest bearing cash at end of year	2013-12-31	$755
Total non interest bearing cash at beginning of year	2013-12-31	$39
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	$779,643
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$4,844,093
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$4,064,450
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	$4,742,451
Value of interest in pooled separate accounts at beginning of year	2013-12-31	$4,033,266
Interest on participant loans	2013-12-31	$2,180
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	$144,040
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$132,677
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	CLIFTONLARSONALLEN LLP
Accountancy firm EIN	2013-12-31	410746749

Form 5500 Responses for MADELIA COMMUNITY HOSPITAL 403(B) PLAN

2022: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: MADELIA COMMUNITY HOSPITAL 403(B) PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: MADELIA COMMUNITY HOSPITAL 403(B) 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	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 funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: MADELIA COMMUNITY HOSPITAL 403(B) 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 – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: MADELIA COMMUNITY HOSPITAL 403(B) 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 – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: MADELIA COMMUNITY HOSPITAL 403(B) 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 – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

664378

Policy instance

Insurance contract or identification number	664378
Number of Individuals Covered	141
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $18,438
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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 $8,067
Insurance broker organization code?	3

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VF6142

Policy instance

Insurance contract or identification number	VF6142
Number of Individuals Covered	4
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $44
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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 $24
Insurance broker organization code?	3

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

080290

Policy instance

Insurance contract or identification number	080290
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Are there contracts with allocated funds for individual policies?	0
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	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

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

B00635

Policy instance

Insurance contract or identification number	B00635
Number of Individuals Covered	3
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Are there contracts with allocated funds for individual policies?	0
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

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

B00635

Policy instance

Insurance contract or identification number	B00635
Number of Individuals Covered	3
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Are there contracts with allocated funds for individual policies?	0
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

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

080290

Policy instance

Insurance contract or identification number	080290
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Are there contracts with allocated funds for individual policies?	0
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

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VF6142

Policy instance

Insurance contract or identification number	VF6142
Number of Individuals Covered	5
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $43
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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 $23
Insurance broker organization code?	3

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

664378

Policy instance

Insurance contract or identification number	664378
Number of Individuals Covered	130
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,792
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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 $1,651
Insurance broker organization code?	3

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

664378

Policy instance

Insurance contract or identification number	664378
Number of Individuals Covered	104
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $15,737
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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 $7,059
Insurance broker organization code?	3

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VF6142

Policy instance

Insurance contract or identification number	VF6142
Number of Individuals Covered	5
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $31
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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 $16
Insurance broker organization code?	3

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

080290

Policy instance

Insurance contract or identification number	080290
Number of Individuals Covered	2
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Are there contracts with allocated funds for individual policies?	0
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

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

B00635

Policy instance

Insurance contract or identification number	B00635
Number of Individuals Covered	3
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Are there contracts with allocated funds for individual policies?	0
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

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

664378

Policy instance

Insurance contract or identification number	664378
Number of Individuals Covered	102
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $15,217
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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	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 $6,843
Insurance broker organization code?	3

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VF6142

Policy instance

Insurance contract or identification number	VF6142
Number of Individuals Covered	6
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,208
Total amount of fees paid to insurance company	USD $37
Are there contracts with allocated funds for individual policies?	0
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 $691
Amount paid for insurance broker fees	37
Additional information about fees paid to insurance broker	SUPPLEMENTAL CASH PAID
Insurance broker organization code?	3

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

080290

Policy instance

Insurance contract or identification number	080290
Number of Individuals Covered	2
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Are there contracts with allocated funds for individual policies?	0
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

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

B00635

Policy instance

Insurance contract or identification number	B00635
Number of Individuals Covered	3
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Are there contracts with allocated funds for individual policies?	0
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

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

B00635

Policy instance

Insurance contract or identification number	B00635
Number of Individuals Covered	3
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Are there contracts with allocated funds for individual policies?	0
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

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

080290

Policy instance

Insurance contract or identification number	080290
Number of Individuals Covered	2
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Are there contracts with allocated funds for individual policies?	0
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

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VF6142

Policy instance

Insurance contract or identification number	VF6142
Number of Individuals Covered	102
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $13,219
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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 $7,636
Insurance broker organization code?	3

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VF6142

Policy instance

Insurance contract or identification number	VF6142
Number of Individuals Covered	95
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $12,354
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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 $7,203
Insurance broker organization code?	3
Insurance broker name	JULIETTE MARTH

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

080290

Policy instance

Insurance contract or identification number	080290
Number of Individuals Covered	2
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Are there contracts with allocated funds for individual policies?	0
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

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

B00635

Policy instance

Insurance contract or identification number	B00635
Number of Individuals Covered	4
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $78
Are there contracts with allocated funds for individual policies?	0
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	78
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BEN SERVICES, INC.

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

B00635

Policy instance

Insurance contract or identification number	B00635
Number of Individuals Covered	4
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $72
Total amount of fees paid to insurance company	USD $95
Are there contracts with allocated funds for types other than group deferred annuity or individual?	Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Other information about contract	GROUP ANNUITY CONTRACT
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	95
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	NFP INS. SERVICES INC.

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

080290

Policy instance

Insurance contract or identification number	080290
Number of Individuals Covered	3
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VF6142

Policy instance

Insurance contract or identification number	VF6142
Number of Individuals Covered	83
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $11,312
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,747
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ANDRE LANKA

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VF6142

Policy instance

Insurance contract or identification number	VF6142
Number of Individuals Covered	91
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $19,279
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,736
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ANDRE LANKA

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

080290

Policy instance

Insurance contract or identification number	080290
Number of Individuals Covered	3
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

B00635

Policy instance

Insurance contract or identification number	B00635
Number of Individuals Covered	4
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $81
Total amount of fees paid to insurance company	USD $91
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	91
Additional information about fees paid to insurance broker	NA
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $81
Insurance broker name	NFP INS. SERVICES INC.

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

080290

Policy instance

Insurance contract or identification number	080290
Number of Individuals Covered	3
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
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	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

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

B00635

Policy instance

Insurance contract or identification number	B00635
Number of Individuals Covered	4
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $78
Total amount of fees paid to insurance company	USD $86
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	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
Amount paid for insurance broker fees	86
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $78
Insurance broker name	NFP INS. SERVICES INC.

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

VF6142

Policy instance

Insurance contract or identification number	VF6142
Number of Individuals Covered	92
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $8,522
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?	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 $5,200
Insurance broker organization code?	3
Insurance broker name	ANDRE LANKA

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Company Name:	MADELIA COMMUNITY HOSPITAL
Employer identification number (EIN):	410758512
NAIC Classification:	622000
NAIC Description:	Hospitals