401k Plan data: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN plan

HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 401k Plan overview

Plan Name	HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN
Plan identification number	502

HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

HENRY J AUSTIN HEALTH CENTER, INC. has sponsored the creation of one or more 401k plans.

Company Name: HENRY J AUSTIN HEALTH CENTER, INC.

Employer identification number (EIN): 222682708

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2023-01-01 CHARLES L. DAVIS, II 2024-10-14
502 2022-01-01 KEMI ALLI 2023-07-24
502 2021-01-01 KEMI ALLI, CHIEF EXECUTIVE OFFICER 2022-07-26
502 2020-01-01 JAMES T. FOLEY 2021-07-20 JAMES T. FOLEY 2021-07-20
502 2019-09-01 JAMES T. FOLEY 2020-07-21 JAMES T. FOLEY 2020-07-21

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2023-01-01	CHARLES L. DAVIS, II	2024-10-14
502	2022-01-01	KEMI ALLI	2023-07-24
502	2021-01-01	KEMI ALLI, CHIEF EXECUTIVE OFFICER	2022-07-26
502	2020-01-01	JAMES T. FOLEY	2021-07-20	JAMES T. FOLEY	2021-07-20
502	2019-09-01	JAMES T. FOLEY	2020-07-21	JAMES T. FOLEY	2020-07-21

Plan Statistics for HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN

401k plan membership statisitcs for HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN

Measure Date Value
2023: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 179
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 189
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 189
2022: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 182
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 179
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 2022-01-01 179
2021: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 154
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 182
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 182
2020: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 155
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 173
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 173
2019: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2019 401k membership
Total participants, beginning-of-year 2019-09-01 153
Total number of active participants reported on line 7a of the Form 5500 2019-09-01 155
Number of retired or separated participants receiving benefits 2019-09-01 0
Number of other retired or separated participants entitled to future benefits 2019-09-01 0
Total of all active and inactive participants 2019-09-01 155

Measure	Date	Value
2023: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	179
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	189
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	189
2022: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	182
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	179
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	179
2021: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	154
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	182
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	182
2020: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	155
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	173
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	173
2019: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2019 401k membership
Total participants, beginning-of-year	2019-09-01	153
Total number of active participants reported on line 7a of the Form 5500	2019-09-01	155
Number of retired or separated participants receiving benefits	2019-09-01	0
Number of other retired or separated participants entitled to future benefits	2019-09-01	0
Total of all active and inactive participants	2019-09-01	155

Form 5500 Responses for HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN

2023: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Submission has been amended	No
2023-01-01	This submission is the final filing	No
2023-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-01-01	Plan is a collectively bargained plan	No
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
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 benefit arrangement – Insurance	Yes
2021: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: HENRY J. AUSTIN HEALTH CENTER LIFE AND DISABILITY PLAN 2019 form 5500 responses
2019-09-01	Type of plan entity	Single employer plan
2019-09-01	First time form 5500 has been submitted	Yes
2019-09-01	Submission has been amended	No
2019-09-01	This submission is the final filing	No
2019-09-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2019-09-01	Plan is a collectively bargained plan	No
2019-09-01	Plan funding arrangement – Insurance	Yes
2019-09-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

001139

Policy instance

Insurance contract or identification number	001139
Number of Individuals Covered	208
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $7,795
Total amount of fees paid to insurance company	USD $4,912
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	Yes
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 $58,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

001139

Policy instance

Insurance contract or identification number	001139
Number of Individuals Covered	189
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,681
Total amount of fees paid to insurance company	USD $4,317
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	Yes
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 $72,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,681
Insurance broker organization code?	3
Amount paid for insurance broker fees	4317
Additional information about fees paid to insurance broker	BONUS

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

001139

Policy instance

Insurance contract or identification number	001139
Number of Individuals Covered	181
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,652
Total amount of fees paid to insurance company	USD $29
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	Yes
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 $39,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,652
Insurance broker organization code?	3
Amount paid for insurance broker fees	29
Additional information about fees paid to insurance broker	BONUS

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

001139

Policy instance

Insurance contract or identification number	001139
Number of Individuals Covered	170
Insurance policy start date	2020-01-20
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,551
Total amount of fees paid to insurance company	USD $3,680
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	Yes
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 $38,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,551
Insurance broker organization code?	3
Amount paid for insurance broker fees	3680
Additional information about fees paid to insurance broker	BONUS

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

001139

Policy instance

Insurance contract or identification number	001139
Number of Individuals Covered	155
Insurance policy start date	2019-09-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,097
Total amount of fees paid to insurance company	USD $4,459
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	Yes
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 $14,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,097
Insurance broker organization code?	3
Amount paid for insurance broker fees	4459
Additional information about fees paid to insurance broker	SERVICE FEE

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Company Name:	HENRY J AUSTIN HEALTH CENTER, INC.
Employer identification number (EIN):	222682708
NAIC Classification:	621498
NAIC Description:	All Other Outpatient Care Centers