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| Plan Name | AGAVE HEALTH MEDICAL PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | AGAVE HEALTH |
| Employer identification number (EIN): | 462971316 |
| NAIC Classification: | 813000 |
| NAIC Description: | Religious, Grantmaking, Civic, Professional, and Similar Organizations |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2015-01-01 | NANCY OCONNOR | NANCY OCONNOR | 2016-06-24 | |
| 501 | 2014-01-01 | ELIZABETH PEREZ | ELIZABETH PEREZ | 2015-07-16 |
| Measure | Date | Value |
|---|---|---|
| 2015: AGAVE HEALTH MEDICAL PLAN 2015 401k membership | ||
| Total participants, beginning-of-year | 2015-01-01 | 284 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 266 |
| Total of all active and inactive participants | 2015-01-01 | 266 |
| 2014: AGAVE HEALTH MEDICAL PLAN 2014 401k membership | ||
| Total participants, beginning-of-year | 2014-01-01 | 132 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 157 |
| Total of all active and inactive participants | 2014-01-01 | 157 |
| 2015: AGAVE HEALTH MEDICAL PLAN 2015 form 5500 responses | ||
|---|---|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: AGAVE HEALTH MEDICAL PLAN 2014 form 5500 responses | ||
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | First time form 5500 has been submitted | Yes |
| 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 benefit arrangement – Insurance | Yes |
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) | |
| Policy contract number | 5469736 |
| Policy instance | 1 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) | |
| Policy contract number | 30045826 |
| Policy instance | 2 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) | |
| Policy contract number | 00610186 |
| Policy instance | 3 |
| DELTA DENTAL OF NEW MEXICO (National Association of Insurance Commissioners NAIC id number: 47287 ) | |
| Policy contract number | 0012210 |
| Policy instance | 4 |
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) | |
| Policy contract number | 5469736 |
| Policy instance | 1 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) | |
| Policy contract number | 30045826 |
| Policy instance | 2 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) | |
| Policy contract number | 00610186 |
| Policy instance | 3 |
| DELTA DENTAL OF NEW MEXICO (National Association of Insurance Commissioners NAIC id number: 47287 ) | |
| Policy contract number | 0012210 |
| Policy instance | 4 |
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