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PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN 401k Plan overview

Plan NamePRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN
Plan identification number 001

PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN Benefits

401k Plan TypeDefined Contribution Pension
Plan Features/Benefits
  • Profit-sharing
  • ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
  • Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
  • Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
  • Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
  • Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
  • Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE has sponsored the creation of one or more 401k plans.

Company Name:PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE
Employer identification number (EIN):420947309
NAIC Classification:621420
NAIC Description:Outpatient Mental Health and Substance Abuse Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
0012022-07-01
0012021-07-01
0012020-07-01
0012019-07-01MICHAEL HUISMAN2021-02-24
0012018-07-01MICHAEL HUISMAN2020-01-08 MICHAEL HUISMAN2020-01-08
0012017-07-01MICHAEL HUISMAN2018-12-21 MICHAEL HUISMAN2018-12-21
0012016-07-01MICHAEL HUISMAN2017-12-12 MICHAEL HUISMAN2017-12-12
0012015-07-01MICHAEL HUISMAN2017-01-10 MICHAEL HUISMAN2017-01-10
0012014-07-01MICHAEL HUISMAN2015-12-28 MICHAEL HUISMAN2015-12-28
0012013-07-01MICHAEL HUISMAN2014-10-28
0012012-07-01MICHAEL HUISMAN2013-11-11 MICHAEL HUISMAN2013-11-11
0012011-07-01MICHAEL HUISMAN2012-11-12
0012010-07-01MICHAEL HUISMAN2011-11-02

Plan Statistics for PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN

401k plan membership statisitcs for PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN

Measure Date Value
2022: PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year2022-07-01153
Total number of active participants reported on line 7a of the Form 55002022-07-01122
Number of retired or separated participants receiving benefits2022-07-016
Number of other retired or separated participants entitled to future benefits2022-07-0136
Total of all active and inactive participants2022-07-01164
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2022-07-010
Total participants2022-07-01164
Number of participants with account balances2022-07-01164
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2022-07-0119
2021: PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year2021-07-01126
Total number of active participants reported on line 7a of the Form 55002021-07-01114
Number of retired or separated participants receiving benefits2021-07-012
Number of other retired or separated participants entitled to future benefits2021-07-0136
Total of all active and inactive participants2021-07-01152
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2021-07-010
Total participants2021-07-01152
Number of participants with account balances2021-07-01152
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2021-07-0111
2020: PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year2020-07-01122
Total number of active participants reported on line 7a of the Form 55002020-07-0192
Number of retired or separated participants receiving benefits2020-07-014
Number of other retired or separated participants entitled to future benefits2020-07-0130
Total of all active and inactive participants2020-07-01126
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2020-07-010
Total participants2020-07-01126
Number of participants with account balances2020-07-01126
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2020-07-0111

Financial Data on PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN

Measure Date Value
2023 : PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN 2023 401k financial data
Total unrealized appreciation/depreciation of assets2023-06-30$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2023-06-30$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2023-06-30$0
Total income from all sources (including contributions)2023-06-30$1,696,248
Total loss/gain on sale of assets2023-06-30$0
Total of all expenses incurred2023-06-30$952,546
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2023-06-30$921,719
Total contributions o plan (from employers,participants, others, non cash contrinutions)2023-06-30$1,044,786
Value of total assets at end of year2023-06-30$5,836,969
Value of total assets at beginning of year2023-06-30$5,093,267
Total of administrative expenses incurred including professional, contract, advisory and management fees2023-06-30$30,827
Total interest from all sources2023-06-30$627
Total dividends received (eg from common stock, registered investment company shares)2023-06-30$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2023-06-30No
Administrative expenses professional fees incurred2023-06-30$30,827
Was this plan covered by a fidelity bond2023-06-30Yes
Value of fidelity bond cover2023-06-30$500,000
If this is an individual account plan, was there a blackout period2023-06-30No
Were there any nonexempt tranactions with any party-in-interest2023-06-30No
Contributions received from participants2023-06-30$526,566
Participant contributions at end of year2023-06-30$10,677
Participant contributions at beginning of year2023-06-30$12,570
Participant contributions at end of year2023-06-30$0
Participant contributions at beginning of year2023-06-30$0
Income. Received or receivable in cash from other sources (including rollovers)2023-06-30$12,574
Total non interest bearing cash at end of year2023-06-30$35,567
Total non interest bearing cash at beginning of year2023-06-30$19,717
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2023-06-30No
Value of net income/loss2023-06-30$743,702
Value of net assets at end of year (total assets less liabilities)2023-06-30$5,836,969
Value of net assets at beginning of year (total assets less liabilities)2023-06-30$5,093,267
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2023-06-30No
Were any loans by the plan or fixed income obligations due to the plan in default2023-06-30No
Were any leases to which the plan was party in default or uncollectible2023-06-30No
Value of interest in registered invesment companies (eg mutual funds) at end of year2023-06-30$5,513,908
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2023-06-30$4,831,629
Interest on participant loans2023-06-30$627
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2023-06-30$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2023-06-30$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)2023-06-30$650,835
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2023-06-30No
Was there a failure to transmit to the plan any participant contributions2023-06-30No
Has the plan failed to provide any benefit when due under the plan2023-06-30No
Contributions received in cash from employer2023-06-30$505,646
Employer contributions (assets) at end of year2023-06-30$276,817
Employer contributions (assets) at beginning of year2023-06-30$229,351
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2023-06-30$921,719
Liabilities. Value of benefit claims payable at end of year2023-06-30$0
Liabilities. Value of benefit claims payable at beginning of year2023-06-30$0
Did the plan have assets held for investment2023-06-30Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2023-06-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2023-06-30No
Opinion of an independent qualified public accountant for this plan2023-06-30Unqualified
Accountancy firm name2023-06-30HOGAN-HANSEN, P.C.
Accountancy firm EIN2023-06-30420991212
2022 : PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets2022-06-30$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-06-30$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-06-30$1,436
Total income from all sources (including contributions)2022-06-30$66,603
Total loss/gain on sale of assets2022-06-30$0
Total of all expenses incurred2022-06-30$883,573
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2022-06-30$852,198
Total contributions o plan (from employers,participants, others, non cash contrinutions)2022-06-30$905,510
Value of total assets at end of year2022-06-30$5,093,267
Value of total assets at beginning of year2022-06-30$5,911,673
Total of administrative expenses incurred including professional, contract, advisory and management fees2022-06-30$31,375
Total interest from all sources2022-06-30$1,103
Total dividends received (eg from common stock, registered investment company shares)2022-06-30$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2022-06-30No
Administrative expenses professional fees incurred2022-06-30$31,375
Was this plan covered by a fidelity bond2022-06-30Yes
Value of fidelity bond cover2022-06-30$500,000
If this is an individual account plan, was there a blackout period2022-06-30Yes
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2022-06-30$0
Were there any nonexempt tranactions with any party-in-interest2022-06-30No
Contributions received from participants2022-06-30$310,495
Participant contributions at end of year2022-06-30$12,570
Participant contributions at beginning of year2022-06-30$23,259
Participant contributions at end of year2022-06-30$0
Participant contributions at beginning of year2022-06-30$0
Income. Received or receivable in cash from other sources (including rollovers)2022-06-30$225,709
Other income not declared elsewhere2022-06-30$-4,319
Total non interest bearing cash at end of year2022-06-30$19,717
Total non interest bearing cash at beginning of year2022-06-30$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2022-06-30No
Value of net income/loss2022-06-30$-816,970
Value of net assets at end of year (total assets less liabilities)2022-06-30$5,093,267
Value of net assets at beginning of year (total assets less liabilities)2022-06-30$5,910,237
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2022-06-30No
Were any loans by the plan or fixed income obligations due to the plan in default2022-06-30No
Were any leases to which the plan was party in default or uncollectible2022-06-30No
Value of interest in registered invesment companies (eg mutual funds) at end of year2022-06-30$4,831,629
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2022-06-30$5,631,716
Interest on participant loans2022-06-30$1,103
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2022-06-30$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2022-06-30$100,987
Net investment gain/loss from registered investment companies (e.g. mutual funds)2022-06-30$-835,691
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2022-06-30No
Was there a failure to transmit to the plan any participant contributions2022-06-30No
Has the plan failed to provide any benefit when due under the plan2022-06-30No
Contributions received in cash from employer2022-06-30$369,306
Employer contributions (assets) at end of year2022-06-30$229,351
Employer contributions (assets) at beginning of year2022-06-30$155,711
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2022-06-30$852,198
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32022-06-30Yes
Liabilities. Value of benefit claims payable at end of year2022-06-30$0
Liabilities. Value of benefit claims payable at beginning of year2022-06-30$1,436
Did the plan have assets held for investment2022-06-30Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2022-06-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2022-06-30No
Opinion of an independent qualified public accountant for this plan2022-06-30Unqualified
Accountancy firm name2022-06-30HOGAN-HANSEN, P.C.
Accountancy firm EIN2022-06-30420991212
2021 : PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets2021-06-30$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-06-30$1,436
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-06-30$0
Total income from all sources (including contributions)2021-06-30$1,821,729
Total loss/gain on sale of assets2021-06-30$0
Total of all expenses incurred2021-06-30$175,052
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2021-06-30$154,409
Total contributions o plan (from employers,participants, others, non cash contrinutions)2021-06-30$537,612
Value of total assets at end of year2021-06-30$5,911,673
Value of total assets at beginning of year2021-06-30$4,263,560
Total of administrative expenses incurred including professional, contract, advisory and management fees2021-06-30$20,643
Total interest from all sources2021-06-30$4,364
Total dividends received (eg from common stock, registered investment company shares)2021-06-30$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-06-30No
Administrative expenses professional fees incurred2021-06-30$20,643
Was this plan covered by a fidelity bond2021-06-30Yes
Value of fidelity bond cover2021-06-30$500,000
If this is an individual account plan, was there a blackout period2021-06-30No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2021-06-30$0
Were there any nonexempt tranactions with any party-in-interest2021-06-30No
Contributions received from participants2021-06-30$263,457
Participant contributions at end of year2021-06-30$23,259
Participant contributions at beginning of year2021-06-30$33,777
Other income not declared elsewhere2021-06-30$4,388
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-06-30No
Value of net income/loss2021-06-30$1,646,677
Value of net assets at end of year (total assets less liabilities)2021-06-30$5,910,237
Value of net assets at beginning of year (total assets less liabilities)2021-06-30$4,263,560
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-06-30No
Were any loans by the plan or fixed income obligations due to the plan in default2021-06-30No
Were any leases to which the plan was party in default or uncollectible2021-06-30No
Value of interest in registered invesment companies (eg mutual funds) at end of year2021-06-30$5,631,716
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2021-06-30$3,918,291
Interest on participant loans2021-06-30$1,700
Interest earned on other investments2021-06-30$2,664
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2021-06-30$100,987
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2021-06-30$163,384
Net investment gain/loss from registered investment companies (e.g. mutual funds)2021-06-30$1,275,365
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-06-30No
Was there a failure to transmit to the plan any participant contributions2021-06-30No
Has the plan failed to provide any benefit when due under the plan2021-06-30No
Contributions received in cash from employer2021-06-30$274,155
Employer contributions (assets) at end of year2021-06-30$155,711
Employer contributions (assets) at beginning of year2021-06-30$148,108
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2021-06-30$154,409
Liabilities. Value of benefit claims payable at end of year2021-06-30$1,436
Liabilities. Value of benefit claims payable at beginning of year2021-06-30$0
Did the plan have assets held for investment2021-06-30Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-06-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-06-30No
Opinion of an independent qualified public accountant for this plan2021-06-30Unqualified
Accountancy firm name2021-06-30HOGAN-HANSEN, P.C.
Accountancy firm EIN2021-06-30420991212

Form 5500 Responses for PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN

2022: PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN 2022 form 5500 responses
2022-07-01Type of plan entitySingle employer plan
2022-07-01Submission has been amendedNo
2022-07-01This submission is the final filingNo
2022-07-01This return/report is a short plan year return/report (less than 12 months)No
2022-07-01Plan is a collectively bargained planNo
2022-07-01Plan funding arrangement – InsuranceYes
2022-07-01Plan funding arrangement – TrustYes
2022-07-01Plan benefit arrangement – InsuranceYes
2022-07-01Plan benefit arrangement - TrustYes
2021: PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01Submission has been amendedNo
2021-07-01This submission is the final filingNo
2021-07-01This return/report is a short plan year return/report (less than 12 months)No
2021-07-01Plan is a collectively bargained planNo
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan funding arrangement – TrustYes
2021-07-01Plan benefit arrangement – InsuranceYes
2021-07-01Plan benefit arrangement - TrustYes
2020: PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE 401(K) PROFIT SHARING PLAN 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Submission has been amendedNo
2020-07-01This submission is the final filingNo
2020-07-01This return/report is a short plan year return/report (less than 12 months)No
2020-07-01Plan is a collectively bargained planNo
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan funding arrangement – TrustYes
2020-07-01Plan benefit arrangement – InsuranceYes
2020-07-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )
Policy contract number150412
Policy instance 1
Insurance contract or identification number150412
Number of Individuals Covered178
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $5,388
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 fees5388
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?5
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number438-80046
Policy instance 1
Insurance contract or identification number438-80046
Number of Individuals Covered152
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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?Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )
Policy contract number150412
Policy instance 2
Insurance contract or identification number150412
Number of Individuals Covered170
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $21,358
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 fees21358
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?5
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number438-80046
Policy instance 1
Insurance contract or identification number438-80046
Number of Individuals Covered141
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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?Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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

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