401k Plan data: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN plan

ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 401k Plan overview

Plan Name	ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN
Plan identification number	506

ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN Benefits

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

ATHOL MEMORIAL HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name: ATHOL MEMORIAL HOSPITAL

Employer identification number (EIN): 042126583

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2016-01-01 ROBERT CROSBY
506 2015-01-01 DONALD J BLOUD
506 2014-01-01 ROBERT CROSBY JR
506 2014-01-01 DONALD J. BLOOD
506 2013-01-01 ROBERT CROSBY
506 2012-01-01 ROBERT CROSBY

Plan id#	Filing Submission Date	Name of Administrator
506	2016-01-01	ROBERT CROSBY
506	2015-01-01	DONALD J BLOUD
506	2014-01-01	ROBERT CROSBY JR
506	2014-01-01	DONALD J. BLOOD
506	2013-01-01	ROBERT CROSBY
506	2012-01-01	ROBERT CROSBY

Plan Statistics for ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN

401k plan membership statisitcs for ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN

Measure Date Value
2016: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 104
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 96
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 96
2015: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 104
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 104
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 2015-01-01 104
2014: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 104
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 104
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 104
2013: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 104
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 104
2012: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 115
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 115

Measure	Date	Value
2016: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	104
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	96
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	96
2015: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	104
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	104
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	104
2014: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	104
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	104
Number of retired or separated participants receiving benefits	2014-01-01	0
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	104
2013: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	104
Number of retired or separated participants receiving benefits	2013-01-01	0
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	104
2012: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	115
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	115

Form 5500 Responses for ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN

2016: ATHOL MEMORIAL HOSPITAL GROUP HEALTH 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 – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 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	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
2014: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
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: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
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 – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: ATHOL MEMORIAL HOSPITAL GROUP HEALTH PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	First time form 5500 has been submitted	Yes
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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MHN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

16252300

Policy instance

Insurance contract or identification number	16252300
Number of Individuals Covered	168
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,621
Total amount of fees paid to insurance company	USD $0
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	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
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 $47,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $9,621
Insurance broker organization code?	3
Insurance broker name

MHN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Insurance contract or identification number	00
Number of Individuals Covered	104
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

MHN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

16252300

Policy instance

Insurance contract or identification number	16252300
Number of Individuals Covered	192
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,465
Total amount of fees paid to insurance company	USD $0
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	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
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 $51,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $9,465
Insurance broker organization code?	3
Insurance broker name

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4956837

Policy instance

Insurance contract or identification number	4956837
Number of Individuals Covered	227
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $40,481
Total amount of fees paid to insurance company	USD $9,360
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	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $26,056
Amount paid for insurance broker fees	9360
Additional information about fees paid to insurance broker	BONUS PERSISTENCY COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER M. POWERS

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4956837

Policy instance

Insurance contract or identification number	4956837
Number of Individuals Covered	266
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $45,246
Total amount of fees paid to insurance company	USD $9,775
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	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $29,410
Amount paid for insurance broker fees	9775
Additional information about fees paid to insurance broker	OTHER COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER M. POWERS

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Company Name:	ATHOL MEMORIAL HOSPITAL
Employer identification number (EIN):	042126583
NAIC Classification:	622000
NAIC Description:	Hospitals