401k Plan data: EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA HEALTH PLAN plan

EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA HEALTH PLAN 401k Plan overview

Plan Name	EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA HEALTH PLAN
Plan identification number	502

EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA HEALTH PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA has sponsored the creation of one or more 401k plans.

Company Name: EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA

Employer identification number (EIN): 250965215

NAIC Classification: 624100
NAIC Description: Individual and Family Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2012-07-01 LAWRENCE P. RAGER JR
502 2012-07-01

Plan Statistics for EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA HEALTH PLAN

401k plan membership statisitcs for EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA HEALTH PLAN

Measure Date Value
2012: EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 109
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 97
Number of retired or separated participants receiving benefits 2012-07-01 3
Number of other retired or separated participants entitled to future benefits 2012-07-01 0
Total of all active and inactive participants 2012-07-01 100

Measure	Date	Value
2012: EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	109
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	97
Number of retired or separated participants receiving benefits	2012-07-01	3
Number of other retired or separated participants entitled to future benefits	2012-07-01	0
Total of all active and inactive participants	2012-07-01	100

Form 5500 Responses for EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA HEALTH PLAN

2012: EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA HEALTH PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	First time form 5500 has been submitted	Yes
2012-07-01	Submission has been amended	Yes
2012-07-01	This submission is the final filing	No
2012-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-07-01	Plan is a collectively bargained plan	No
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )

Policy contract number

5924960000

Policy instance

Insurance contract or identification number	5924960000
Number of Individuals Covered	119
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $22,358
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $687,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,358
Insurance broker organization code?	3
Insurance broker name	TUCKER JOHNSTON & SMELZER, INC.

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00468444

Policy instance

Insurance contract or identification number	00468444
Number of Individuals Covered	76
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,300
Total amount of fees paid to insurance company	USD $3,206
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,235
Amount paid for insurance broker fees	3206
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	LIFETIME FINANCIAL GROWTH, LLC

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

01545572

Policy instance

Insurance contract or identification number	01545572
Number of Individuals Covered	51
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $6,182
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $278,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,182
Insurance broker organization code?	3
Insurance broker name	TUCKER JOHNSTON & SMELZER, INC.

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

896324

Policy instance

Insurance contract or identification number	896324
Number of Individuals Covered	46
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,559
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,559
Insurance broker organization code?	3
Insurance broker name	TUCKER JOHNSTON & SMELZER, INC.

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

2892

Policy instance

Insurance contract or identification number	2892
Number of Individuals Covered	19
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $174
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $174
Insurance broker organization code?	3
Insurance broker name	TUCKER JOHNSTON & SMELZER, INC.

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Company Name:	EASTER SEALS WESTERN AND CENTRAL PENNSYLVANIA
Employer identification number (EIN):	250965215
NAIC Classification:	624100
NAIC Description:	Individual and Family Services