401k Plan data: OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN plan

OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN 401k Plan overview

Plan Name	OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN
Plan identification number	504

OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Temporary disability (accident and sickness)

401k Sponsoring company profile

OUTER CAPE HEALTH SERVICES has sponsored the creation of one or more 401k plans.

Company Name: OUTER CAPE HEALTH SERVICES

Employer identification number (EIN): 042509828

NAIC Classification: 621399
NAIC Description: Offices of All Other Miscellaneous Health Practitioners

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
504 2014-04-01 SALLY DEANE
504 2013-04-01 SALLY DEANE

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
504	2014-04-01	SALLY DEANE
504	2013-04-01	SALLY DEANE

Plan Statistics for OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN

401k plan membership statisitcs for OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN

Measure Date Value
2014: OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN 2014 401k membership
Total participants, beginning-of-year 2014-04-01 143
Total number of active participants reported on line 7a of the Form 5500 2014-04-01 0
Number of retired or separated participants receiving benefits 2014-04-01 0
Number of other retired or separated participants entitled to future benefits 2014-04-01 0
Total of all active and inactive participants 2014-04-01 0
2013: OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN 2013 401k membership
Total participants, beginning-of-year 2013-04-01 100
Total number of active participants reported on line 7a of the Form 5500 2013-04-01 119
Number of retired or separated participants receiving benefits 2013-04-01 0
Number of other retired or separated participants entitled to future benefits 2013-04-01 0
Total of all active and inactive participants 2013-04-01 119

Measure	Date	Value
2014: OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN 2014 401k membership
Total participants, beginning-of-year	2014-04-01	143
Total number of active participants reported on line 7a of the Form 5500	2014-04-01	0
Number of retired or separated participants receiving benefits	2014-04-01	0
Number of other retired or separated participants entitled to future benefits	2014-04-01	0
Total of all active and inactive participants	2014-04-01	0
2013: OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN 2013 401k membership
Total participants, beginning-of-year	2013-04-01	100
Total number of active participants reported on line 7a of the Form 5500	2013-04-01	119
Number of retired or separated participants receiving benefits	2013-04-01	0
Number of other retired or separated participants entitled to future benefits	2013-04-01	0
Total of all active and inactive participants	2013-04-01	119

Form 5500 Responses for OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN

2014: OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN 2014 form 5500 responses
2014-04-01	Type of plan entity	Single employer plan
2014-04-01	Submission has been amended	No
2014-04-01	This submission is the final filing	Yes
2014-04-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2014-04-01	Plan is a collectively bargained plan	No
2014-04-01	Plan funding arrangement – Insurance	Yes
2014-04-01	Plan benefit arrangement – Insurance	Yes
2013: OUTER CAPE HEALTH SERVICES SHORT TERM DISABILITY PLAN 2013 form 5500 responses
2013-04-01	Type of plan entity	Single employer plan
2013-04-01	First time form 5500 has been submitted	Yes
2013-04-01	Submission has been amended	No
2013-04-01	This submission is the final filing	No
2013-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-04-01	Plan is a collectively bargained plan	No
2013-04-01	Plan funding arrangement – Insurance	Yes
2013-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG0APBG

Policy instance

Insurance contract or identification number	GUG0APBG
Number of Individuals Covered	128
Insurance policy start date	2014-04-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,912
Total amount of fees paid to insurance company	USD $760
Are there contracts with allocated funds for individual policies?	No
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $19,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $194
Insurance broker organization code?	3
Amount paid for insurance broker fees	760
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG0APBG

Policy instance

Insurance contract or identification number	GUG0APBG
Number of Individuals Covered	119
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $2,328
Total amount of fees paid to insurance company	USD $369
Are there contracts with allocated funds for individual policies?	No
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $23,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,328
Amount paid for insurance broker fees	369
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	1
Insurance broker name	RICHARD R RACINE

Potentially related plans

OUTER CAPE FINISHERS, INC. PROFIT SHARING PLAN [EIN = 042829558]

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Company Name:	OUTER CAPE HEALTH SERVICES
Employer identification number (EIN):	042509828
NAIC Classification:	621399
NAIC Description:	Offices of All Other Miscellaneous Health Practitioners