401k Plan data: BUCKEYE AMBULANCE, LLC 401(K) PLAN plan

BUCKEYE AMBULANCE, LLC 401(K) PLAN 401k Plan overview

Plan Name	BUCKEYE AMBULANCE, LLC 401(K) PLAN
Plan identification number	001

BUCKEYE AMBULANCE, LLC 401(K) PLAN Benefits

401k Plan Type

Defined 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.
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

BUCKEYE AMBULANCE, LLC has sponsored the creation of one or more 401k plans.

Company Name: BUCKEYE AMBULANCE, LLC

Employer identification number (EIN): 455077555

NAIC Classification: 485990

Additional information about BUCKEYE AMBULANCE, LLC

Jurisdiction of Incorporation: Ohio Secretary of State Business Services Division

Incorporation Date: 2011-04-18

Company Identification Number: 2014220

Legal Registered Office Address: 1531 JOHN GLENN RD
-
DAYTON
United States of America (USA)
45410

More information about BUCKEYE AMBULANCE, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BUCKEYE AMBULANCE, LLC 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2019-01-01 DERECK PRISTAS 2020-10-14 DERECK PRISTAS 2020-10-14
001 2018-01-01 DERECK PRISTAS 2019-10-14 DERECK PRISTAS 2019-10-14
001 2017-01-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2019-01-01	DERECK PRISTAS	2020-10-14	DERECK PRISTAS	2020-10-14
001	2018-01-01	DERECK PRISTAS	2019-10-14	DERECK PRISTAS	2019-10-14
001	2017-01-01

Plan Statistics for BUCKEYE AMBULANCE, LLC 401(K) PLAN

401k plan membership statisitcs for BUCKEYE AMBULANCE, LLC 401(K) PLAN

Measure Date Value
2019: BUCKEYE AMBULANCE, LLC 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 199
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 206
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 33
Total of all active and inactive participants 2019-01-01 239
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 239
Number of participants with account balances 2019-01-01 72
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 5
2018: BUCKEYE AMBULANCE, LLC 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 176
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 153
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 20
Total of all active and inactive participants 2018-01-01 173
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 173
Number of participants with account balances 2018-01-01 54
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 11
2017: BUCKEYE AMBULANCE, LLC 401(K) PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 179
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 182
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 3
Total of all active and inactive participants 2017-01-01 185
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 185
Number of participants with account balances 2017-01-01 27
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 3

Measure	Date	Value
2019: BUCKEYE AMBULANCE, LLC 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	199
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	206
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	33
Total of all active and inactive participants	2019-01-01	239
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	239
Number of participants with account balances	2019-01-01	72
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	5
2018: BUCKEYE AMBULANCE, LLC 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	176
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	153
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	20
Total of all active and inactive participants	2018-01-01	173
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	173
Number of participants with account balances	2018-01-01	54
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	11
2017: BUCKEYE AMBULANCE, LLC 401(K) PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	179
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	182
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	3
Total of all active and inactive participants	2017-01-01	185
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	185
Number of participants with account balances	2017-01-01	27
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	3

Financial Data on BUCKEYE AMBULANCE, LLC 401(K) PLAN

Measure	Date	Value
2019 : BUCKEYE AMBULANCE, LLC 401(K) 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	$262,592
Total income from all sources (including contributions)	2019-12-31	$262,592
Total loss/gain on sale of assets	2019-12-31	$0
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$31,197
Total of all expenses incurred	2019-12-31	$31,197
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$31,197
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$31,197
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$215,258
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$215,258
Value of total assets at end of year	2019-12-31	$426,335
Value of total assets at end of year	2019-12-31	$426,335
Value of total assets at beginning of year	2019-12-31	$194,940
Value of total assets at beginning of year	2019-12-31	$194,940
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$0
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$0
Total interest from all sources	2019-12-31	$0
Total interest from all sources	2019-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$0
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
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	$10,000
Value of fidelity bond cover	2019-12-31	$10,000
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
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	$122,767
Contributions received from participants	2019-12-31	$122,767
Participant contributions at end of year	2019-12-31	$2,445
Participant contributions at end of year	2019-12-31	$2,445
Participant contributions at beginning of year	2019-12-31	$4,029
Participant contributions at beginning of year	2019-12-31	$4,029
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$25,579
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$25,579
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2019-12-31	$0
Administrative expenses (other) incurred	2019-12-31	$0
Administrative expenses (other) incurred	2019-12-31	$0
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	$231,395
Value of net income/loss	2019-12-31	$231,395
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$426,335
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$426,335
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$194,940
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$194,940
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	$382,835
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$382,835
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$169,353
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$169,353
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$47,334
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$47,334
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
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	$66,912
Contributions received in cash from employer	2019-12-31	$66,912
Employer contributions (assets) at end of year	2019-12-31	$41,055
Employer contributions (assets) at end of year	2019-12-31	$41,055
Employer contributions (assets) at beginning of year	2019-12-31	$21,558
Employer contributions (assets) at beginning of year	2019-12-31	$21,558
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$31,197
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$31,197
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	BENNETT, GROEBER, MULLEN & FELTNER
Accountancy firm name	2019-12-31	BENNETT, GROEBER, MULLEN & FELTNER
Accountancy firm EIN	2019-12-31	341601163
Accountancy firm EIN	2019-12-31	341601163
2018 : BUCKEYE AMBULANCE, LLC 401(K) PLAN 2018 401k financial data
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	$39,363
Total income from all sources (including contributions)	2018-12-31	$164,846
Total of all expenses incurred	2018-12-31	$11,392
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$7,047
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$175,299
Value of total assets at end of year	2018-12-31	$194,940
Value of total assets at beginning of year	2018-12-31	$80,849
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$4,345
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	$4,345
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$10,000
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	$115,073
Participant contributions at end of year	2018-12-31	$4,029
Participant contributions at beginning of year	2018-12-31	$6,147
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2018-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2018-12-31	$39,363
Other income not declared elsewhere	2018-12-31	$1,090
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	$153,454
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$194,940
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$41,486
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 registered invesment companies (eg mutual funds) at end of year	2018-12-31	$169,353
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$73,097
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-11,543
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	$60,226
Employer contributions (assets) at end of year	2018-12-31	$21,558
Employer contributions (assets) at beginning of year	2018-12-31	$1,605
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$7,047
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	BENNETT, GROEBER, MULLEN & FELTNER
Accountancy firm EIN	2018-12-31	341601163
2017 : BUCKEYE AMBULANCE, LLC 401(K) PLAN 2017 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$39,363
Total income from all sources (including contributions)	2017-12-31	$83,988
Total of all expenses incurred	2017-12-31	$42,502
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$4,411
Value of total corrective distributions	2017-12-31	$38,091
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$82,237
Value of total assets at end of year	2017-12-31	$80,849
Value of total assets at beginning of year	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
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$10,000
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	$64,512
Participant contributions at end of year	2017-12-31	$6,147
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2017-12-31	$39,363
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	$41,486
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$41,486
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$0
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 registered invesment companies (eg mutual funds) at end of year	2017-12-31	$73,097
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-12-31	$1,751
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	$17,725
Employer contributions (assets) at end of year	2017-12-31	$1,605
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$4,411
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

Form 5500 Responses for BUCKEYE AMBULANCE, LLC 401(K) PLAN

2019: BUCKEYE AMBULANCE, LLC 401(K) 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: BUCKEYE AMBULANCE, LLC 401(K) 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: BUCKEYE AMBULANCE, LLC 401(K) 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 – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

127150

Policy instance

Insurance contract or identification number	127150
Number of Individuals Covered	64
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	775
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION
Insurance broker organization code?	1

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

127150

Policy instance

Insurance contract or identification number	127150
Number of Individuals Covered	54
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Insurance broker organization code?	1

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

127150

Policy instance

Insurance contract or identification number	127150
Number of Individuals Covered	28
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 $0
Insurance broker organization code?	1
Insurance broker name	CAPITAL PENSION GROUP, LLC

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Company Name:	BUCKEYE AMBULANCE, LLC
Employer identification number (EIN):	455077555
NAIC Classification:	485990

Jurisdiction of Incorporation:	Ohio Secretary of State Business Services Division
Incorporation Date:	2011-04-18
Company Identification Number:	2014220
Legal Registered Office Address:	1531 JOHN GLENN RD - DAYTON United States of America (USA) 45410