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| Plan Name | ST. LAWRENCE HEALTH SYSTEM WELFARE BENEFIT PLAN FOR GOUVERNEUR HOSPITAL |
| Plan identification number | 520 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | GOUVERNEUR HOSPITAL |
| Employer identification number (EIN): | 464249555 |
| NAIC Classification: | 622000 |
| NAIC Description: | Hospitals |
Additional information about GOUVERNEUR HOSPITAL
| Jurisdiction of Incorporation: | New York Department of State |
| Incorporation Date: | 2013-12-05 |
| Company Identification Number: | 4496686 |
| Legal Registered Office Address: |
C/O CHIEF EXECUTIVE OFFICER 77 WEST BARNEY STREET GOUVERNEUR United States of America (USA) 13642 |
More information about GOUVERNEUR HOSPITAL
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 520 | 2023-01-01 | HOWARD GLASTONBURY | 2024-09-13 | ||
| 520 | 2022-01-01 | ||||
| 520 | 2022-01-01 | KELLY CICCHINELLI | |||
| 520 | 2021-01-01 | ||||
| 520 | 2021-01-01 | DONNA MCGREGOR | |||
| 520 | 2020-01-01 | ||||
| 520 | 2019-01-01 | ||||
| 520 | 2018-01-01 | ||||
| 520 | 2017-01-01 | ERIC BURCH | |||
| 520 | 2016-01-01 | SUZAN L. MCDERMOTT | |||
| 520 | 2015-01-01 | RICHARD LANG | |||
| 520 | 2014-01-01 | RICHARD LANG |
| 2023: ST. LAWRENCE HEALTH SYSTEM WELFARE BENEFIT PLAN FOR GOUVERNEUR HOSPITAL 2023 form 5500 responses | ||
|---|---|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Plan is a collectively bargained plan | Yes |
| 2023-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: ST. LAWRENCE HEALTH SYSTEM WELFARE BENEFIT PLAN FOR GOUVERNEUR HOSPITAL 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 | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: ST. LAWRENCE HEALTH SYSTEM WELFARE BENEFIT PLAN FOR GOUVERNEUR HOSPITAL 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 | Yes |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: ST. LAWRENCE HEALTH SYSTEM WELFARE BENEFIT PLAN FOR GOUVERNEUR HOSPITAL 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 benefit arrangement – Insurance | Yes |
| 2019: ST. LAWRENCE HEALTH SYSTEM WELFARE BENEFIT PLAN FOR GOUVERNEUR HOSPITAL 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 benefit arrangement – Insurance | Yes |
| 2018: ST. LAWRENCE HEALTH SYSTEM WELFARE BENEFIT PLAN FOR GOUVERNEUR HOSPITAL 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 benefit arrangement – Insurance | Yes |
| 2017: ST. LAWRENCE HEALTH SYSTEM WELFARE BENEFIT PLAN FOR GOUVERNEUR HOSPITAL 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 benefit arrangement – Insurance | Yes |
| 2016: ST. LAWRENCE HEALTH SYSTEM WELFARE BENEFIT PLAN FOR GOUVERNEUR HOSPITAL 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 benefit arrangement – Insurance | Yes |
| 2015: ST. LAWRENCE HEALTH SYSTEM WELFARE BENEFIT PLAN FOR GOUVERNEUR HOSPITAL 2015 form 5500 responses | ||
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | First time form 5500 has been submitted | Yes |
| 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: ST. LAWRENCE HEALTH SYSTEM WELFARE BENEFIT PLAN FOR GOUVERNEUR HOSPITAL 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 funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) | |
| Policy contract number | G000BBP6 |
| Policy instance | 2 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |
| Policy contract number | 00494840 |
| Policy instance | 1 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |
| Policy contract number | 00494840 |
| Policy instance | 1 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) | |
| Policy contract number | MP 0BBP6 |
| Policy instance | 2 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) | |
| Policy contract number | GHA 0BBP6 |
| Policy instance | 3 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) | |
| Policy contract number | GMC 0BBP6 |
| Policy instance | 4 |
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) | |
| Policy contract number | GLCL0BBP6 |
| Policy instance | 5 |
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) | |
| Policy contract number | GCEL0BBP6 |
| Policy instance | 6 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) | |
| Policy contract number | 00513201 |
| Policy instance | 7 |
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) | |
| Policy contract number | GLCL0BBP6 |
| Policy instance | 6 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) | |
| Policy contract number | GMC 0BBP6 |
| Policy instance | 5 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) | |
| Policy contract number | 00513201 |
| Policy instance | 4 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) | |
| Policy contract number | GHA 0BBP6 |
| Policy instance | 3 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) | |
| Policy contract number | MP 0BBP6 |
| Policy instance | 2 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |
| Policy contract number | 00494840 |
| Policy instance | 1 |
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) | |
| Policy contract number | GCEL0BBP6 |
| Policy instance | 7 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) | |
| Policy contract number | GMC 0BBP6 |
| Policy instance | 7 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) | |
| Policy contract number | 00122548 |
| Policy instance | 6 |
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) | |
| Policy contract number | GLCL0BBP6 |
| Policy instance | 8 |
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) | |
| Policy contract number | GCEL0BBP6 |
| Policy instance | 9 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) | |
| Policy contract number | 00513201 |
| Policy instance | 5 |
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) | |
| Policy contract number | 823318 |
| Policy instance | 3 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) | |
| Policy contract number | GHA 0BBP6 |
| Policy instance | 4 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) | |
| Policy contract number | MP 0BBP6 |
| Policy instance | 2 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |
| Policy contract number | 00494840 |
| Policy instance | 1 |
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) | |
| Policy contract number | 823318 |
| Policy instance | 4 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) | |
| Policy contract number | 00513201 |
| Policy instance | 3 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |
| Policy contract number | 494840 |
| Policy instance | 2 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) | |
| Policy contract number | 00122548 |
| Policy instance | 1 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) | |
| Policy contract number | 00122548 |
| Policy instance | 1 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |
| Policy contract number | 494840 |
| Policy instance | 2 |
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) | |
| Policy contract number | 823318 |
| Policy instance | 3 |
| THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 89009 ) | |
| Policy contract number | 445187 |
| Policy instance | 4 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |
| Policy contract number | 494840 |
| Policy instance | 3 |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) | |
| Policy contract number | 00122548 |
| Policy instance | 2 |
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) | |
| Policy contract number | 823318 |
| Policy instance | 1 |
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