401k Plan data: HORIZON BLUE CROSS BLUE SHIELD OMNIA plan

HORIZON BLUE CROSS BLUE SHIELD OMNIA 401k Plan overview

Plan Name	HORIZON BLUE CROSS BLUE SHIELD OMNIA
Plan identification number	501

HORIZON BLUE CROSS BLUE SHIELD OMNIA Benefits

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

401k Sponsoring company profile

HORIZON HEALTHCARE SERVICES, INC. has sponsored the creation of one or more 401k plans.

Company Name: HORIZON HEALTHCARE SERVICES, INC.

Employer identification number (EIN): 220999690

NAIC Classification: 524140

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HORIZON BLUE CROSS BLUE SHIELD OMNIA

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-02-01

Plan Statistics for HORIZON BLUE CROSS BLUE SHIELD OMNIA

401k plan membership statisitcs for HORIZON BLUE CROSS BLUE SHIELD OMNIA

Measure Date Value
2019: HORIZON BLUE CROSS BLUE SHIELD OMNIA 2019 401k membership
Total participants, beginning-of-year 2019-02-01 90
Total number of active participants reported on line 7a of the Form 5500 2019-02-01 104
Number of retired or separated participants receiving benefits 2019-02-01 0
Number of other retired or separated participants entitled to future benefits 2019-02-01 0
Total of all active and inactive participants 2019-02-01 104
Total participants 2019-02-01 104

Measure	Date	Value
2019: HORIZON BLUE CROSS BLUE SHIELD OMNIA 2019 401k membership
Total participants, beginning-of-year	2019-02-01	90
Total number of active participants reported on line 7a of the Form 5500	2019-02-01	104
Number of retired or separated participants receiving benefits	2019-02-01	0
Number of other retired or separated participants entitled to future benefits	2019-02-01	0
Total of all active and inactive participants	2019-02-01	104
Total participants	2019-02-01	104

Form 5500 Responses for HORIZON BLUE CROSS BLUE SHIELD OMNIA

2019: HORIZON BLUE CROSS BLUE SHIELD OMNIA 2019 form 5500 responses
2019-02-01	Type of plan entity	Single employer plan
2019-02-01	First time form 5500 has been submitted	Yes
2019-02-01	Submission has been amended	No
2019-02-01	This submission is the final filing	No
2019-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-02-01	Plan is a collectively bargained plan	No
2019-02-01	Plan funding arrangement – Insurance	Yes
2019-02-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

Policy instance

Number of Individuals Covered	104
Insurance policy start date	2019-02-01
Insurance policy end date	2020-01-31
Total amount of commissions paid to insurance broker	USD $40,113
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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	No
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?	No
Commission paid to Insurance Broker	USD $40,112
Amount paid for insurance broker fees	0

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Company Name:	HORIZON HEALTHCARE SERVICES, INC.
Employer identification number (EIN):	220999690
NAIC Classification:	524140