401k Plan data: MIDLAND COMMUNITY HEALTH SERVICES BENEFITS plan

MIDLAND COMMUNITY HEALTH SERVICES BENEFITS 401k Plan overview

Plan Name	MIDLAND COMMUNITY HEALTH SERVICES BENEFITS
Plan identification number	501

MIDLAND COMMUNITY HEALTH SERVICES BENEFITS Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

MIDLAND COMMUNITY HEALTHCARE SERVICES, INC. has sponsored the creation of one or more 401k plans.

Company Name: MIDLAND COMMUNITY HEALTHCARE SERVICES, INC.

Employer identification number (EIN): 830358685

NAIC Classification: 621498
NAIC Description: All Other Outpatient Care Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MIDLAND COMMUNITY HEALTH SERVICES BENEFITS

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-03-01 CLARENCE ZACHARY 2023-08-23

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-03-01	CLARENCE ZACHARY	2023-08-23

Plan Statistics for MIDLAND COMMUNITY HEALTH SERVICES BENEFITS

401k plan membership statisitcs for MIDLAND COMMUNITY HEALTH SERVICES BENEFITS

Measure Date Value
2022: MIDLAND COMMUNITY HEALTH SERVICES BENEFITS 2022 401k membership
Total participants, beginning-of-year 2022-03-01 108
Total number of active participants reported on line 7a of the Form 5500 2022-03-01 98
Number of retired or separated participants receiving benefits 2022-03-01 0
Number of other retired or separated participants entitled to future benefits 2022-03-01 0
Total of all active and inactive participants 2022-03-01 98
Number of employers contributing to the scheme 2022-03-01 0

Measure	Date	Value
2022: MIDLAND COMMUNITY HEALTH SERVICES BENEFITS 2022 401k membership
Total participants, beginning-of-year	2022-03-01	108
Total number of active participants reported on line 7a of the Form 5500	2022-03-01	98
Number of retired or separated participants receiving benefits	2022-03-01	0
Number of other retired or separated participants entitled to future benefits	2022-03-01	0
Total of all active and inactive participants	2022-03-01	98
Number of employers contributing to the scheme	2022-03-01	0

Form 5500 Responses for MIDLAND COMMUNITY HEALTH SERVICES BENEFITS

2022: MIDLAND COMMUNITY HEALTH SERVICES BENEFITS 2022 form 5500 responses
2022-03-01	Type of plan entity	Single employer plan
2022-03-01	First time form 5500 has been submitted	Yes
2022-03-01	Plan funding arrangement – Insurance	Yes
2022-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

195221

Policy instance

Insurance contract or identification number	195221
Number of Individuals Covered	222
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $38,400
Total amount of fees paid to insurance company	USD $990
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,216,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $38,400
Amount paid for insurance broker fees	990
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30003219

Policy instance

Insurance contract or identification number	30003219
Number of Individuals Covered	87
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,382
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,382
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

167303

Policy instance

Insurance contract or identification number	167303
Number of Individuals Covered	111
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $22,224
Total amount of fees paid to insurance company	USD $5,556
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $10,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,224
Amount paid for insurance broker fees	2743
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3

Potentially related plans

MIDLAND COMMUNITY BANK PROFIT SHARING PLAN AND TRUST [EIN = 370902554]

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Company Name:	MIDLAND COMMUNITY HEALTHCARE SERVICES, INC.
Employer identification number (EIN):	830358685
NAIC Classification:	621498
NAIC Description:	All Other Outpatient Care Centers