401k Plan data: SUPPLEMENTAL MEDICAL plan

SUPPLEMENTAL MEDICAL 401k Plan overview

Plan Name	SUPPLEMENTAL MEDICAL
Plan identification number	515

SUPPLEMENTAL MEDICAL Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision)

401k Sponsoring company profile

NORTHWEST PERMANENTE, P.C. has sponsored the creation of one or more 401k plans.

Company Name: NORTHWEST PERMANENTE, P.C.

Employer identification number (EIN): 930698548

NAIC Classification: 621112
NAIC Description: Offices of Physicians, Mental Health Specialists

Additional information about NORTHWEST PERMANENTE, P.C.

Jurisdiction of Incorporation: Oregon Secretary of State Corporations Division

Incorporation Date: 1977-11-30

Company Identification Number: 12511713

Legal Registered Office Address: 500 NE MULTNOMAH ST STE 100

PORTLAND
United States of America (USA)
97232

More information about NORTHWEST PERMANENTE, P.C.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SUPPLEMENTAL MEDICAL

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
515 2015-01-01 HARRY STATHOS
515 2014-01-01 HARRY STATHOS
515 2013-01-01 HARRY STATHOS
515 2012-01-01 ANN STENZEL HARRY STATHOS 2013-09-25
515 2011-01-01 ANN STENZEL HARRY STATHOS 2012-10-01
515 2010-01-01 ANN STENZEL HARRY STATHOS 2011-10-03
515 2009-01-01 ANN STENZEL RICHARD SHIMOMURA 2010-09-23

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
515	2015-01-01	HARRY STATHOS
515	2014-01-01	HARRY STATHOS
515	2013-01-01	HARRY STATHOS
515	2012-01-01	ANN STENZEL	HARRY STATHOS	2013-09-25
515	2011-01-01	ANN STENZEL	HARRY STATHOS	2012-10-01
515	2010-01-01	ANN STENZEL	HARRY STATHOS	2011-10-03
515	2009-01-01	ANN STENZEL	RICHARD SHIMOMURA	2010-09-23

Plan Statistics for SUPPLEMENTAL MEDICAL

401k plan membership statisitcs for SUPPLEMENTAL MEDICAL

Measure Date Value
2015: SUPPLEMENTAL MEDICAL 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,477
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 0
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 0
2014: SUPPLEMENTAL MEDICAL 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,439
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,469
Number of retired or separated participants receiving benefits 2014-01-01 8
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 1,477
2013: SUPPLEMENTAL MEDICAL 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,720
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,392
Number of retired or separated participants receiving benefits 2013-01-01 442
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 1,834
2012: SUPPLEMENTAL MEDICAL 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,600
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1,720
Total of all active and inactive participants 2012-01-01 1,720
2011: SUPPLEMENTAL MEDICAL 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,539
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,227
Number of retired or separated participants receiving benefits 2011-01-01 373
Total of all active and inactive participants 2011-01-01 1,600
2010: SUPPLEMENTAL MEDICAL 2010 401k membership
Total participants, beginning-of-year 2010-01-01 1,431
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 1,203
Number of retired or separated participants receiving benefits 2010-01-01 336
Total of all active and inactive participants 2010-01-01 1,539
2009: SUPPLEMENTAL MEDICAL 2009 401k membership
Total participants, beginning-of-year 2009-01-01 1,385
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 1,113
Number of retired or separated participants receiving benefits 2009-01-01 318
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 1,431

Measure	Date	Value
2015: SUPPLEMENTAL MEDICAL 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,477
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	0
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	0
2014: SUPPLEMENTAL MEDICAL 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,439
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,469
Number of retired or separated participants receiving benefits	2014-01-01	8
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	1,477
2013: SUPPLEMENTAL MEDICAL 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,720
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,392
Number of retired or separated participants receiving benefits	2013-01-01	442
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	1,834
2012: SUPPLEMENTAL MEDICAL 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,600
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,720
Total of all active and inactive participants	2012-01-01	1,720
2011: SUPPLEMENTAL MEDICAL 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,539
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,227
Number of retired or separated participants receiving benefits	2011-01-01	373
Total of all active and inactive participants	2011-01-01	1,600
2010: SUPPLEMENTAL MEDICAL 2010 401k membership
Total participants, beginning-of-year	2010-01-01	1,431
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	1,203
Number of retired or separated participants receiving benefits	2010-01-01	336
Total of all active and inactive participants	2010-01-01	1,539
2009: SUPPLEMENTAL MEDICAL 2009 401k membership
Total participants, beginning-of-year	2009-01-01	1,385
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	1,113
Number of retired or separated participants receiving benefits	2009-01-01	318
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	1,431

Form 5500 Responses for SUPPLEMENTAL MEDICAL

2015: SUPPLEMENTAL MEDICAL 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	Yes
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: SUPPLEMENTAL MEDICAL 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: SUPPLEMENTAL MEDICAL 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	Yes
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: SUPPLEMENTAL MEDICAL 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: SUPPLEMENTAL MEDICAL 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: SUPPLEMENTAL MEDICAL 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: SUPPLEMENTAL MEDICAL 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

MODA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number	10000120
Policy instance	1
MODA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number	10000120
Policy instance	1
ODS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number	10000120M
Policy instance	1
ODS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number	10000120M
Policy instance	1
ODS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number	10000120M
Policy instance	1
ODS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number	10000120M
Policy instance	1

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Company Name:	NORTHWEST PERMANENTE, P.C.
Employer identification number (EIN):	930698548
NAIC Classification:	621112
NAIC Description:	Offices of Physicians, Mental Health Specialists

Jurisdiction of Incorporation:	Oregon Secretary of State Corporations Division
Incorporation Date:	1977-11-30
Company Identification Number:	12511713
Legal Registered Office Address:	500 NE MULTNOMAH ST STE 100 PORTLAND United States of America (USA) 97232