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HOMETOWN URGENT CARE WELFARE BENEFIT PLAN 401k Plan overview

Plan NameHOMETOWN URGENT CARE WELFARE BENEFIT PLAN
Plan identification number 501

HOMETOWN URGENT CARE WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

URGENT CARE SPECIALISTS, LLC has sponsored the creation of one or more 401k plans.

Company Name:URGENT CARE SPECIALISTS, LLC
Employer identification number (EIN):203587332
NAIC Classification:621111
NAIC Description:Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOMETOWN URGENT CARE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012015-12-01CHRIS HALE
5012014-12-01CHRIS HALE
5012013-12-01CHRIS HALE
5012013-08-01MANOJ KUMAR
5012012-08-01MANOJ KUMAR

Plan Statistics for HOMETOWN URGENT CARE WELFARE BENEFIT PLAN

401k plan membership statisitcs for HOMETOWN URGENT CARE WELFARE BENEFIT PLAN

Measure Date Value
2015: HOMETOWN URGENT CARE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-12-01168
Total number of active participants reported on line 7a of the Form 55002015-12-010
Number of retired or separated participants receiving benefits2015-12-010
Number of other retired or separated participants entitled to future benefits2015-12-010
Total of all active and inactive participants2015-12-010
2014: HOMETOWN URGENT CARE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-12-01170
Total number of active participants reported on line 7a of the Form 55002014-12-01168
Number of retired or separated participants receiving benefits2014-12-010
Number of other retired or separated participants entitled to future benefits2014-12-010
Total of all active and inactive participants2014-12-01168
2013: HOMETOWN URGENT CARE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-12-01170
Total number of active participants reported on line 7a of the Form 55002013-12-01127
Number of retired or separated participants receiving benefits2013-12-010
Number of other retired or separated participants entitled to future benefits2013-12-010
Total of all active and inactive participants2013-12-01127
Total participants, beginning-of-year2013-08-01154
Total number of active participants reported on line 7a of the Form 55002013-08-01167
Number of retired or separated participants receiving benefits2013-08-013
Number of other retired or separated participants entitled to future benefits2013-08-010
Total of all active and inactive participants2013-08-01170
2012: HOMETOWN URGENT CARE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-08-01126
Total number of active participants reported on line 7a of the Form 55002012-08-01154
Number of retired or separated participants receiving benefits2012-08-010
Number of other retired or separated participants entitled to future benefits2012-08-010
Total of all active and inactive participants2012-08-01154

Form 5500 Responses for HOMETOWN URGENT CARE WELFARE BENEFIT PLAN

2015: HOMETOWN URGENT CARE WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-12-01Type of plan entitySingle employer plan
2015-12-01Submission has been amendedNo
2015-12-01This submission is the final filingYes
2015-12-01This return/report is a short plan year return/report (less than 12 months)Yes
2015-12-01Plan is a collectively bargained planNo
2015-12-01Plan funding arrangement – InsuranceYes
2015-12-01Plan benefit arrangement – InsuranceYes
2014: HOMETOWN URGENT CARE WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-12-01Type of plan entitySingle employer plan
2014-12-01Submission has been amendedNo
2014-12-01This submission is the final filingNo
2014-12-01This return/report is a short plan year return/report (less than 12 months)No
2014-12-01Plan is a collectively bargained planNo
2014-12-01Plan funding arrangement – InsuranceYes
2014-12-01Plan benefit arrangement – InsuranceYes
2013: HOMETOWN URGENT CARE WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-12-01Type of plan entitySingle employer plan
2013-12-01Submission has been amendedNo
2013-12-01This submission is the final filingNo
2013-12-01This return/report is a short plan year return/report (less than 12 months)No
2013-12-01Plan is a collectively bargained planNo
2013-12-01Plan funding arrangement – InsuranceYes
2013-12-01Plan benefit arrangement – InsuranceYes
2013-08-01Type of plan entitySingle employer plan
2013-08-01Submission has been amendedNo
2013-08-01This submission is the final filingNo
2013-08-01This return/report is a short plan year return/report (less than 12 months)Yes
2013-08-01Plan is a collectively bargained planNo
2013-08-01Plan funding arrangement – InsuranceYes
2013-08-01Plan benefit arrangement – InsuranceYes
2012: HOMETOWN URGENT CARE WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-08-01Type of plan entitySingle employer plan
2012-08-01Plan funding arrangement – InsuranceYes
2012-08-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00490343
Policy instance 1
Insurance contract or identification number00490343
Number of Individuals Covered0
Insurance policy start date2015-12-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $1,613
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 CarrierUSD $14,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,613
Insurance broker organization code?3
Insurance broker nameMCGOHAN BARBENDER, INC.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00490343
Policy instance 1
Insurance contract or identification number00490343
Number of Individuals Covered146
Insurance policy start date2014-12-01
Insurance policy end date2015-11-30
Total amount of commissions paid to insurance brokerUSD $12,372
Total amount of fees paid to insurance companyUSD $3,995
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 CarrierUSD $144,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,372
Amount paid for insurance broker fees3995
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameMCGOHAN BARBENDER, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number815239
Policy instance 2
Insurance contract or identification number815239
Number of Individuals Covered143
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Total amount of commissions paid to insurance brokerUSD $1,462
Total amount of fees paid to insurance companyUSD $8,048
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $859,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,462
Amount paid for insurance broker fees8048
Additional information about fees paid to insurance brokerFFES
Insurance broker organization code?3
Insurance broker nameMCGOHAN BRABDNER, INC.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00490343
Policy instance 1
Insurance contract or identification number00490343
Number of Individuals Covered127
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Total amount of commissions paid to insurance brokerUSD $9,201
Total amount of fees paid to insurance companyUSD $3,136
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 CarrierUSD $114,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,139
Amount paid for insurance broker fees3136
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameMCGOHAN BRABENDER, INC.
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number00171739
Policy instance 1
Insurance contract or identification number00171739
Number of Individuals Covered154
Insurance policy start date2013-08-01
Insurance policy end date2013-11-30
Total amount of commissions paid to insurance brokerUSD $3,612
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $262,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,612
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00490343
Policy instance 2
Insurance contract or identification number00490343
Number of Individuals Covered157
Insurance policy start date2013-08-01
Insurance policy end date2013-11-30
Total amount of commissions paid to insurance brokerUSD $4,570
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 CarrierUSD $43,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,570
Insurance broker organization code?3
Insurance broker nameOSWALD COMPANY
AETNA BETTER HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 14229 )
Policy contract number847387
Policy instance 1
Insurance contract or identification number847387
Number of Individuals Covered168
Insurance policy start date2012-05-25
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $3,571
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $42,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,571
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number00171739
Policy instance 2
Insurance contract or identification number00171739
Number of Individuals Covered204
Insurance policy start date2012-06-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $31,941
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $489,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,815
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameCBISA REACQUISITION CORP

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