CITIZENS MEDICAL CENTER has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST
401k plan membership statisitcs for CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST
| Measure | Date | Value |
|---|
| 2021: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-12-01 | 76 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-12-01 | 80 |
| Total of all active and inactive participants | 2021-12-01 | 80 |
| 2020: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-01 | 82 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-01 | 76 |
| Total of all active and inactive participants | 2020-12-01 | 76 |
| 2019: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 85 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 82 |
| Total of all active and inactive participants | 2019-12-01 | 82 |
| 2018: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-01 | 80 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-01 | 85 |
| Total of all active and inactive participants | 2018-12-01 | 85 |
| 2017: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 81 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 80 |
| Total of all active and inactive participants | 2017-12-01 | 80 |
| 2016: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-01 | 84 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 81 |
| Total of all active and inactive participants | 2016-12-01 | 81 |
| 2015: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-01 | 82 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 84 |
| Total of all active and inactive participants | 2015-12-01 | 84 |
| 2014: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-12-01 | 77 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-12-01 | 82 |
| Total of all active and inactive participants | 2014-12-01 | 82 |
| 2013: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-12-01 | 88 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-12-01 | 77 |
| Total of all active and inactive participants | 2013-12-01 | 77 |
| 2012: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-12-01 | 78 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-12-01 | 76 |
| Total of all active and inactive participants | 2012-12-01 | 76 |
| 2011: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-12-01 | 78 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-12-01 | 78 |
| Total of all active and inactive participants | 2011-12-01 | 78 |
| 2009: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-12-01 | 70 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-12-01 | 77 |
| Total of all active and inactive participants | 2009-12-01 | 77 |
| Measure | Date | Value |
|---|
| 2022 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2022 401k financial data |
|---|
| Total income from all sources | 2022-11-30 | $1,522,928 |
| Expenses. Total of all expenses incurred | 2022-11-30 | $1,507,330 |
| Benefits paid (including direct rollovers) | 2022-11-30 | $1,466,115 |
| Total plan assets at end of year | 2022-11-30 | $38,851 |
| Total plan assets at beginning of year | 2022-11-30 | $23,253 |
| Expenses. Other expenses not covered elsewhere | 2022-11-30 | $41,215 |
| Other income received | 2022-11-30 | $80,024 |
| Net income (gross income less expenses) | 2022-11-30 | $15,598 |
| Net plan assets at end of year (total assets less liabilities) | 2022-11-30 | $38,851 |
| Net plan assets at beginning of year (total assets less liabilities) | 2022-11-30 | $23,253 |
| Total contributions received or receivable from employer(s) | 2022-11-30 | $1,442,904 |
| 2021 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2021 401k financial data |
|---|
| Total income from all sources | 2021-11-30 | $889,005 |
| Expenses. Total of all expenses incurred | 2021-11-30 | $897,586 |
| Benefits paid (including direct rollovers) | 2021-11-30 | $854,318 |
| Total plan assets at end of year | 2021-11-30 | $23,253 |
| Total plan assets at beginning of year | 2021-11-30 | $31,834 |
| Expenses. Other expenses not covered elsewhere | 2021-11-30 | $43,268 |
| Net income (gross income less expenses) | 2021-11-30 | $-8,581 |
| Net plan assets at end of year (total assets less liabilities) | 2021-11-30 | $23,253 |
| Net plan assets at beginning of year (total assets less liabilities) | 2021-11-30 | $31,834 |
| Total contributions received or receivable from employer(s) | 2021-11-30 | $889,005 |
| 2020 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2020 401k financial data |
|---|
| Total income from all sources | 2020-11-30 | $1,253,210 |
| Expenses. Total of all expenses incurred | 2020-11-30 | $1,224,449 |
| Benefits paid (including direct rollovers) | 2020-11-30 | $1,180,976 |
| Total plan assets at end of year | 2020-11-30 | $31,834 |
| Total plan assets at beginning of year | 2020-11-30 | $3,073 |
| Expenses. Other expenses not covered elsewhere | 2020-11-30 | $43,473 |
| Other income received | 2020-11-30 | $62,475 |
| Net income (gross income less expenses) | 2020-11-30 | $28,761 |
| Net plan assets at end of year (total assets less liabilities) | 2020-11-30 | $31,834 |
| Net plan assets at beginning of year (total assets less liabilities) | 2020-11-30 | $3,073 |
| Total contributions received or receivable from employer(s) | 2020-11-30 | $1,190,735 |
| 2019 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2019 401k financial data |
|---|
| Total income from all sources | 2019-11-30 | $1,409,247 |
| Expenses. Total of all expenses incurred | 2019-11-30 | $1,557,551 |
| Benefits paid (including direct rollovers) | 2019-11-30 | $1,511,959 |
| Total plan assets at end of year | 2019-11-30 | $3,073 |
| Total plan assets at beginning of year | 2019-11-30 | $151,377 |
| Expenses. Other expenses not covered elsewhere | 2019-11-30 | $45,592 |
| Other income received | 2019-11-30 | $168,567 |
| Net income (gross income less expenses) | 2019-11-30 | $-148,304 |
| Net plan assets at end of year (total assets less liabilities) | 2019-11-30 | $3,073 |
| Net plan assets at beginning of year (total assets less liabilities) | 2019-11-30 | $151,377 |
| Total contributions received or receivable from employer(s) | 2019-11-30 | $1,240,680 |
| 2018 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2018 401k financial data |
|---|
| Total income from all sources | 2018-11-30 | $1,249,699 |
| Expenses. Total of all expenses incurred | 2018-11-30 | $1,170,982 |
| Benefits paid (including direct rollovers) | 2018-11-30 | $1,130,864 |
| Total plan assets at end of year | 2018-11-30 | $151,377 |
| Total plan assets at beginning of year | 2018-11-30 | $72,660 |
| Expenses. Other expenses not covered elsewhere | 2018-11-30 | $40,118 |
| Other income received | 2018-11-30 | $136,989 |
| Net income (gross income less expenses) | 2018-11-30 | $78,717 |
| Net plan assets at end of year (total assets less liabilities) | 2018-11-30 | $151,377 |
| Net plan assets at beginning of year (total assets less liabilities) | 2018-11-30 | $72,660 |
| Total contributions received or receivable from employer(s) | 2018-11-30 | $1,112,710 |
| 2017 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2017 401k financial data |
|---|
| Total income from all sources | 2017-11-30 | $1,540,632 |
| Expenses. Total of all expenses incurred | 2017-11-30 | $1,516,108 |
| Benefits paid (including direct rollovers) | 2017-11-30 | $1,474,253 |
| Total plan assets at end of year | 2017-11-30 | $72,660 |
| Total plan assets at beginning of year | 2017-11-30 | $48,136 |
| Expenses. Other expenses not covered elsewhere | 2017-11-30 | $41,855 |
| Other income received | 2017-11-30 | $179,619 |
| Net income (gross income less expenses) | 2017-11-30 | $24,524 |
| Net plan assets at end of year (total assets less liabilities) | 2017-11-30 | $72,660 |
| Net plan assets at beginning of year (total assets less liabilities) | 2017-11-30 | $48,136 |
| Total contributions received or receivable from employer(s) | 2017-11-30 | $1,361,013 |
| 2016 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2016 401k financial data |
|---|
| Total income from all sources | 2016-11-30 | $1,463,723 |
| Expenses. Total of all expenses incurred | 2016-11-30 | $1,442,848 |
| Benefits paid (including direct rollovers) | 2016-11-30 | $1,398,464 |
| Total plan assets at end of year | 2016-11-30 | $48,136 |
| Total plan assets at beginning of year | 2016-11-30 | $27,261 |
| Expenses. Other expenses not covered elsewhere | 2016-11-30 | $44,384 |
| Other income received | 2016-11-30 | $13,637 |
| Net income (gross income less expenses) | 2016-11-30 | $20,875 |
| Net plan assets at end of year (total assets less liabilities) | 2016-11-30 | $48,136 |
| Net plan assets at beginning of year (total assets less liabilities) | 2016-11-30 | $27,261 |
| Total contributions received or receivable from employer(s) | 2016-11-30 | $1,450,086 |
| 2015 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2015 401k financial data |
|---|
| Total income from all sources | 2015-11-30 | $1,421,020 |
| Expenses. Total of all expenses incurred | 2015-11-30 | $1,425,628 |
| Benefits paid (including direct rollovers) | 2015-11-30 | $1,380,337 |
| Total plan assets at end of year | 2015-11-30 | $27,261 |
| Total plan assets at beginning of year | 2015-11-30 | $31,869 |
| Expenses. Other expenses not covered elsewhere | 2015-11-30 | $45,291 |
| Other income received | 2015-11-30 | $487,623 |
| Net income (gross income less expenses) | 2015-11-30 | $-4,608 |
| Net plan assets at end of year (total assets less liabilities) | 2015-11-30 | $27,261 |
| Net plan assets at beginning of year (total assets less liabilities) | 2015-11-30 | $31,869 |
| Total contributions received or receivable from employer(s) | 2015-11-30 | $933,397 |
| 2014 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2014 401k financial data |
|---|
| Total income from all sources | 2014-11-30 | $846,737 |
| Expenses. Total of all expenses incurred | 2014-11-30 | $819,667 |
| Benefits paid (including direct rollovers) | 2014-11-30 | $774,687 |
| Total plan assets at end of year | 2014-11-30 | $31,869 |
| Total plan assets at beginning of year | 2014-11-30 | $4,799 |
| Expenses. Other expenses not covered elsewhere | 2014-11-30 | $44,980 |
| Other income received | 2014-11-30 | $106,084 |
| Net income (gross income less expenses) | 2014-11-30 | $27,070 |
| Net plan assets at end of year (total assets less liabilities) | 2014-11-30 | $31,869 |
| Net plan assets at beginning of year (total assets less liabilities) | 2014-11-30 | $4,799 |
| Total contributions received or receivable from employer(s) | 2014-11-30 | $740,653 |
| 2013 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2013 401k financial data |
|---|
| Total income from all sources | 2013-11-30 | $803,289 |
| Expenses. Total of all expenses incurred | 2013-11-30 | $837,695 |
| Benefits paid (including direct rollovers) | 2013-11-30 | $802,053 |
| Total plan assets at end of year | 2013-11-30 | $4,799 |
| Total plan assets at beginning of year | 2013-11-30 | $39,205 |
| Expenses. Other expenses not covered elsewhere | 2013-11-30 | $35,642 |
| Other income received | 2013-11-30 | $240,041 |
| Net income (gross income less expenses) | 2013-11-30 | $-34,406 |
| Net plan assets at end of year (total assets less liabilities) | 2013-11-30 | $4,799 |
| Net plan assets at beginning of year (total assets less liabilities) | 2013-11-30 | $39,205 |
| Total contributions received or receivable from employer(s) | 2013-11-30 | $563,248 |
| 2012 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2012 401k financial data |
|---|
| Total income from all sources | 2012-11-30 | $1,231,458 |
| Expenses. Total of all expenses incurred | 2012-11-30 | $1,216,962 |
| Benefits paid (including direct rollovers) | 2012-11-30 | $1,176,596 |
| Total plan assets at end of year | 2012-11-30 | $39,205 |
| Total plan assets at beginning of year | 2012-11-30 | $24,709 |
| Other income received | 2012-11-30 | $209,506 |
| Net income (gross income less expenses) | 2012-11-30 | $14,496 |
| Net plan assets at end of year (total assets less liabilities) | 2012-11-30 | $39,205 |
| Net plan assets at beginning of year (total assets less liabilities) | 2012-11-30 | $24,709 |
| Total contributions received or receivable from employer(s) | 2012-11-30 | $1,021,952 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2012-11-30 | $40,366 |
| 2011 : CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2011 401k financial data |
|---|
| Total income from all sources | 2011-11-30 | $918,586 |
| Expenses. Total of all expenses incurred | 2011-11-30 | $905,173 |
| Benefits paid (including direct rollovers) | 2011-11-30 | $867,039 |
| Total plan assets at end of year | 2011-11-30 | $24,709 |
| Total plan assets at beginning of year | 2011-11-30 | $11,296 |
| Other income received | 2011-11-30 | $230,602 |
| Net income (gross income less expenses) | 2011-11-30 | $13,413 |
| Net plan assets at end of year (total assets less liabilities) | 2011-11-30 | $24,709 |
| Net plan assets at beginning of year (total assets less liabilities) | 2011-11-30 | $11,296 |
| Total contributions received or receivable from employer(s) | 2011-11-30 | $687,984 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2011-11-30 | $38,134 |
| 2021: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2021 form 5500 responses |
|---|
| 2021-12-01 | Type of plan entity | Single employer plan |
| 2021-12-01 | Plan funding arrangement – Insurance | Yes |
| 2021-12-01 | Plan funding arrangement – Trust | Yes |
| 2021-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-12-01 | Plan benefit arrangement - Trust | Yes |
| 2020: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2020 form 5500 responses |
|---|
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | Plan funding arrangement – Insurance | Yes |
| 2020-12-01 | Plan funding arrangement – Trust | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement - Trust | Yes |
| 2019: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan funding arrangement – Trust | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement - Trust | Yes |
| 2018: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan funding arrangement – Trust | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement - Trust | Yes |
| 2017: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan funding arrangement – Trust | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement - Trust | Yes |
| 2016: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan funding arrangement – Trust | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement - Trust | Yes |
| 2015: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan funding arrangement – Trust | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement - Trust | Yes |
| 2014: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2014 form 5500 responses |
|---|
| 2014-12-01 | Type of plan entity | Single employer plan |
| 2014-12-01 | Plan funding arrangement – Insurance | Yes |
| 2014-12-01 | Plan funding arrangement – Trust | Yes |
| 2014-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-12-01 | Plan benefit arrangement - Trust | Yes |
| 2013: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2013 form 5500 responses |
|---|
| 2013-12-01 | Type of plan entity | Single employer plan |
| 2013-12-01 | Plan funding arrangement – Insurance | Yes |
| 2013-12-01 | Plan funding arrangement – Trust | Yes |
| 2013-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-12-01 | Plan benefit arrangement - Trust | Yes |
| 2012: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2012 form 5500 responses |
|---|
| 2012-12-01 | Type of plan entity | Single employer plan |
| 2012-12-01 | Plan funding arrangement – Insurance | Yes |
| 2012-12-01 | Plan funding arrangement – Trust | Yes |
| 2012-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-12-01 | Plan benefit arrangement - Trust | Yes |
| 2011: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2011 form 5500 responses |
|---|
| 2011-12-01 | Type of plan entity | Single employer plan |
| 2011-12-01 | Plan funding arrangement – Insurance | Yes |
| 2011-12-01 | Plan funding arrangement – Trust | Yes |
| 2011-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-12-01 | Plan benefit arrangement - Trust | Yes |
| 2009: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2009 form 5500 responses |
|---|
| 2009-12-01 | Type of plan entity | Single employer plan |
| 2009-12-01 | This submission is the final filing | No |
| 2009-12-01 | Plan funding arrangement – Insurance | Yes |
| 2009-12-01 | Plan funding arrangement – Trust | Yes |
| 2009-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-12-01 | Plan benefit arrangement - Trust | Yes |
| 2008: CITIZENS MEDICAL CENTER EMPLOYEE BENEFIT PLAN & TRUST 2008 form 5500 responses |
|---|
| 2008-12-01 | Type of plan entity | Single employer plan |
| 2008-12-01 | Submission has been amended | No |
| 2008-12-01 | This submission is the final filing | No |
| 2008-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-12-01 | Plan is a collectively bargained plan | No |
| VERITY HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 5 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 80 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $1,868 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $6,538 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,868 | | Insurance broker organization code? | 5 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 4 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 80 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $5,181 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | SUPPLEMENTAL LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $25,545 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,181 | | Insurance broker organization code? | 5 |
|
| PHOENIX EXCESS RISK (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 3 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 80 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $52,844 | | Total amount of fees paid to insurance company | USD $36,853 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Other welfare benefits provided | COMPLIANCE | | Welfare Benefit Premiums Paid to Carrier | USD $348,373 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $52,844 | | Amount paid for insurance broker fees | 36853 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMIN FEES | | Insurance broker organization code? | 5 |
|
| PPO PLUS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 2 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 80 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $2,335 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $10,741 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,335 | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 1 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 80 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $796 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,826 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $796 | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 1 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 76 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $801 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,988 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $801 | | Insurance broker organization code? | 5 |
|
| PPO PLUS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 2 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 76 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $2,458 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $11,305 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,458 | | Insurance broker organization code? | 5 |
|
| PHOENIX EXCESS RISK (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 3 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 76 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $53,874 | | Total amount of fees paid to insurance company | USD $39,541 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Other welfare benefits provided | COMPLIANCE | | Welfare Benefit Premiums Paid to Carrier | USD $355,032 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,874 | | Amount paid for insurance broker fees | 39541 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMIN FEES | | Insurance broker organization code? | 5 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 4 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 76 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $5,387 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | SUPPLEMENTAL LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $26,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,387 | | Insurance broker organization code? | 5 |
|
| VERITY HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 5 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 76 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $1,966 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $6,881 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,966 | | Insurance broker organization code? | 5 |
|
| VERITY HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 6 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 82 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $3,465 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $8,415 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 5 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 82 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $5,030 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | SUPPLEMENTAL LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $25,151 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PHOENIX EXCESS RISK (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 4 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 82 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $61,417 | | Total amount of fees paid to insurance company | USD $38,779 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Other welfare benefits provided | COMPLIANCE | | Welfare Benefit Premiums Paid to Carrier | USD $405,303 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PPO PLUS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 3 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 82 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $990 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $9,903 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HEALTH HOLDINGS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 2 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 82 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $1,703 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | PRE-CERTIFICATION | | Welfare Benefit Premiums Paid to Carrier | USD $4,356 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 1 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 82 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $818 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,070 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 1 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 85 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $860 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,278 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $860 | | Insurance broker organization code? | 5 |
|
| AMERICAN HEALTH HOLDINGS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 2 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 85 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $1,614 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | PRE-CERTIFICATION | | Welfare Benefit Premiums Paid to Carrier | USD $4,349 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,614 | | Insurance broker organization code? | 5 |
|
| PPO PLUS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 3 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 85 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $2,620 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $8,908 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,620 | | Insurance broker organization code? | 5 |
|
| PHOENIX EXCESS RISK (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 4 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 85 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $73,574 | | Total amount of fees paid to insurance company | USD $38,405 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Other welfare benefits provided | COMPLIANCE | | Welfare Benefit Premiums Paid to Carrier | USD $484,270 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $73,574 | | Amount paid for insurance broker fees | 38405 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMIN FEES | | Insurance broker organization code? | 5 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 5 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 85 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $4,634 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | SUPPLEMENTAL LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $23,174 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,634 | | Insurance broker organization code? | 5 |
|
| VERITY HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 6 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 85 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $2,096 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $6,288 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,096 | | Insurance broker organization code? | 5 |
|
| VERITY HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 6 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 80 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $2,445 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $6,356 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 5 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 80 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $4,397 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | SUPPLEMENTAL LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $21,987 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PHOENIX EXCESS RISK (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 4 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 80 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $58,541 | | Total amount of fees paid to insurance company | USD $35,653 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Other welfare benefits provided | COMPLIANCE | | Welfare Benefit Premiums Paid to Carrier | USD $396,818 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PPO PLUS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 3 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 80 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $1,959 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $7,827 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HEALTH HOLDINGS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 2 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 80 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $1,321 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | PRECERTIFICATION | | Welfare Benefit Premiums Paid to Carrier | USD $3,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | NOT AVAILABLE |
| Policy instance | 1 |
| Insurance contract or identification number | NOT AVAILABLE | | Number of Individuals Covered | 80 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $740 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,679 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
