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| Plan Name | BROOKHAVEN LIFE PLAN |
| Plan identification number | 502 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | BROOKHAVEN HOSPITAL |
| Employer identification number (EIN): | 742362662 |
| NAIC Classification: | 622000 |
| NAIC Description: | Hospitals |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 502 | 2021-10-01 | CASSIE FLYNN | 2022-12-29 | ||
| 502 | 2021-10-01 | JANET PALMER | 2024-01-03 | ||
| 502 | 2020-10-01 | SHERRY ENRIGHT | 2022-04-08 |
| Measure | Date | Value |
|---|---|---|
| 2021: BROOKHAVEN LIFE PLAN 2021 401k membership | ||
| Total participants, beginning-of-year | 2021-10-01 | 150 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 264 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 264 |
| Number of employers contributing to the scheme | 2021-10-01 | 0 |
| 2020: BROOKHAVEN LIFE PLAN 2020 401k membership | ||
| Total participants, beginning-of-year | 2020-10-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 150 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 150 |
| Number of employers contributing to the scheme | 2020-10-01 | 0 |
| 2021: BROOKHAVEN LIFE PLAN 2021 form 5500 responses | ||
|---|---|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Submission has been amended | Yes |
| 2021-10-01 | This submission is the final filing | Yes |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: BROOKHAVEN LIFE PLAN 2020 form 5500 responses | ||
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | First time form 5500 has been submitted | Yes |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) | |||||||||||||||||||||||||||||||
| Policy contract number | 873678G | ||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |||||||||||||||||||||||||||||||
| Policy contract number | 531012 | ||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||
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| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) | |||||||||||||||||||||||||||||||
| Policy contract number | VF025891 | ||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||
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