| Plan Name | PRIVIA MEDICAL GROUP - GULF COAST HEALTH AND WELFARE PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
|
| Company Name: | PRIVIA MEDICAL GROUP - GULF COAST |
| Employer identification number (EIN): | 422456505 |
| NAIC Classification: | 621111 |
| NAIC Description: | Offices of Physicians (except Mental Health Specialists) |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2017-01-01 | FRED HUANG |
| 2017: PRIVIA MEDICAL GROUP - GULF COAST HEALTH AND WELFARE PLAN 2017 form 5500 responses | ||
|---|---|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | First time form 5500 has been submitted | Yes |
| 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 – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | LK964994 |
| Policy instance | 1 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | OK968785 |
| Policy instance | 2 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | FLX967274 |
| Policy instance | 3 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | LK751994 |
| Policy instance | 4 |
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 128646 |
| Policy instance | 5 |
| KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 ) | |
| Policy contract number | 599332 |
| Policy instance | 6 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |
| Policy contract number | 534685 |
| Policy instance | 7 |