401k Plan data: NORTHWEST SPECIALTY HOSPITAL MEDICAL, DENTAL AND VISION PLAN plan

NORTHWEST SPECIALTY HOSPITAL MEDICAL, DENTAL AND VISION PLAN 401k Plan overview

Plan Name	NORTHWEST SPECIALTY HOSPITAL MEDICAL, DENTAL AND VISION PLAN
Plan identification number	502

NORTHWEST SPECIALTY HOSPITAL MEDICAL, DENTAL AND VISION PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision

401k Sponsoring company profile

NORTH IDAHO DAY SURGERY, LLC DBA NORTHWEST SPECIALTY HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name: NORTH IDAHO DAY SURGERY, LLC DBA NORTHWEST SPECIALTY HOSPITAL

Employer identification number (EIN): 200002031

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NORTHWEST SPECIALTY HOSPITAL MEDICAL, DENTAL AND VISION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2010-01-01 RICK RASMUSSEN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2010-01-01	RICK RASMUSSEN

Plan Statistics for NORTHWEST SPECIALTY HOSPITAL MEDICAL, DENTAL AND VISION PLAN

401k plan membership statisitcs for NORTHWEST SPECIALTY HOSPITAL MEDICAL, DENTAL AND VISION PLAN

Measure Date Value
2010: NORTHWEST SPECIALTY HOSPITAL MEDICAL, DENTAL AND VISION PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 181
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 196
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 196

Measure	Date	Value
2010: NORTHWEST SPECIALTY HOSPITAL MEDICAL, DENTAL AND VISION PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	181
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	196
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	196

Form 5500 Responses for NORTHWEST SPECIALTY HOSPITAL MEDICAL, DENTAL AND VISION PLAN

2010: NORTHWEST SPECIALTY HOSPITAL MEDICAL, DENTAL AND VISION PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

REGENCE BLUESHIELD OF IDAHO (National Association of Insurance Commissioners NAIC id number: 60131 )

Policy contract number

60012751

Policy instance

Insurance contract or identification number	60012751
Number of Individuals Covered	434
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $45,388
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	Yes
Vision Insurance Welfare Benefit	Yes
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 $1,576,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,388
Insurance broker organization code?	3
Insurance broker name	ROBERT P. NONINI

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Company Name:	NORTH IDAHO DAY SURGERY, LLC DBA NORTHWEST SPECIALTY HOSPITAL
Employer identification number (EIN):	200002031
NAIC Classification:	622000
NAIC Description:	Hospitals