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| Plan Name | SPECIALTY MEDICAL GROUP LIFE AND ADD PLAN |
| Plan identification number | 504 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | VALLEY CHILDREN'S SPECIALTY MEDICAL GROUP, INC. |
| Employer identification number (EIN): | 770450620 |
| NAIC Classification: | 621111 |
| NAIC Description: | Offices of Physicians (except Mental Health Specialists) |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 504 | 2017-01-01 | ||||
| 504 | 2016-01-01 | SHERVIN SHAMS | |||
| 504 | 2015-01-01 | LOURDINE SKILLIN |
| Measure | Date | Value |
|---|---|---|
| 2017: SPECIALTY MEDICAL GROUP LIFE AND ADD PLAN 2017 401k membership | ||
| Total participants, beginning-of-year | 2017-01-01 | 156 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 0 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 0 |
| 2016: SPECIALTY MEDICAL GROUP LIFE AND ADD PLAN 2016 401k membership | ||
| Total participants, beginning-of-year | 2016-01-01 | 138 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 156 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 156 |
| 2015: SPECIALTY MEDICAL GROUP LIFE AND ADD PLAN 2015 401k membership | ||
| Total participants, beginning-of-year | 2015-01-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 138 |
| 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 | 138 |
| 2017: SPECIALTY MEDICAL GROUP LIFE AND ADD PLAN 2017 form 5500 responses | ||
|---|---|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | This submission is the final filing | Yes |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: SPECIALTY MEDICAL GROUP LIFE AND ADD PLAN 2016 form 5500 responses | ||
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: SPECIALTY MEDICAL GROUP LIFE AND ADD PLAN 2015 form 5500 responses | ||
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | First time form 5500 has been submitted | Yes |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 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 benefit arrangement – Insurance | Yes |
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | W0063507 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 154103 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 154103 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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