401k Plan data: NORTH BEND MEDICAL CENTER HEALTH AND WELFARE EMPLOYEE BENEFIT PLAN plan

NORTH BEND MEDICAL CENTER HEALTH AND WELFARE EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	NORTH BEND MEDICAL CENTER HEALTH AND WELFARE EMPLOYEE BENEFIT PLAN
Plan identification number	506

NORTH BEND MEDICAL CENTER HEALTH AND WELFARE EMPLOYEE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

NORTH BEND MEDICAL CENTER has sponsored the creation of one or more 401k plans.

Company Name: NORTH BEND MEDICAL CENTER

Employer identification number (EIN): 930635514

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NORTH BEND MEDICAL CENTER HEALTH AND WELFARE EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2022-01-01

Plan Statistics for NORTH BEND MEDICAL CENTER HEALTH AND WELFARE EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for NORTH BEND MEDICAL CENTER HEALTH AND WELFARE EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: NORTH BEND MEDICAL CENTER HEALTH AND WELFARE EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 351
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 342
Number of retired or separated participants receiving benefits 2022-01-01 8
Number of other retired or separated participants entitled to future benefits 2022-01-01 6
Total of all active and inactive participants 2022-01-01 356
Total participants 2022-01-01 356

Measure	Date	Value
2022: NORTH BEND MEDICAL CENTER HEALTH AND WELFARE EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	351
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	342
Number of retired or separated participants receiving benefits	2022-01-01	8
Number of other retired or separated participants entitled to future benefits	2022-01-01	6
Total of all active and inactive participants	2022-01-01	356
Total participants	2022-01-01	356

Form 5500 Responses for NORTH BEND MEDICAL CENTER HEALTH AND WELFARE EMPLOYEE BENEFIT PLAN

2022: NORTH BEND MEDICAL CENTER HEALTH AND WELFARE EMPLOYEE BENEFIT PLAN 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	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	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )

Policy contract number

G0037733

Policy instance

Insurance contract or identification number	G0037733
Number of Individuals Covered	299
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $329,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63983 )

Policy contract number

03426

Policy instance

Insurance contract or identification number	03426
Number of Individuals Covered	135
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $345
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $46,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $345
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63983 )

Policy contract number

GD-03426

Policy instance

Insurance contract or identification number	GD-03426
Number of Individuals Covered	418
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $255
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $149,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $255
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63983 )

Policy contract number

63983

Policy instance

Insurance contract or identification number	63983
Number of Individuals Covered	388
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $45
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $17,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	NORTH BEND MEDICAL CENTER
Employer identification number (EIN):	930635514
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)