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| Plan Name | 504 LIFE/ VOL LIFE/EAP |
| Plan identification number | 504 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | OB/GYN AFFILIATES |
| Employer identification number (EIN): | 841520625 |
| NAIC Classification: | 621111 |
| NAIC Description: | Offices of Physicians (except Mental Health Specialists) |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 504 | 2022-01-01 | CHRIS HRUBESKY | 2023-07-14 |
| Measure | Date | Value |
|---|---|---|
| 2022: 504 LIFE/ VOL LIFE/EAP 2022 401k membership | ||
| Total participants, beginning-of-year | 2022-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 0 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 0 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2022: 504 LIFE/ VOL LIFE/EAP 2022 form 5500 responses | ||
|---|---|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | First time form 5500 has been submitted | Yes |
| 2022-01-01 | This submission is the final filing | Yes |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |||||||||||||||||||||||||||||
| Policy contract number | SGM611936 | ||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||
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