401k Plan data: PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN plan

PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN 401k Plan overview

Plan Name	PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN
Plan identification number	506

PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Vision Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

PEN BAY HEALTHCARE has sponsored the creation of one or more 401k plans.

Company Name: PEN BAY HEALTHCARE

Employer identification number (EIN): 222494474

NAIC Classification: 622000
NAIC Description: Hospitals

Additional information about PEN BAY HEALTHCARE

Jurisdiction of Incorporation: Maine Bureau of Corporations, Elections & Commissions

Incorporation Date:

Company Identification Number: 19830167ND

More information about PEN BAY HEALTHCARE

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2012-01-01 CATHERINE A MCKEOWN
506 2011-01-01 CATHERINE AQ. MCKEOWN
506 2009-01-01 CATHERINE MCKEOWN CATHERINE MCKEOWN 2010-07-30

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
506	2012-01-01	CATHERINE A MCKEOWN
506	2011-01-01	CATHERINE AQ. MCKEOWN
506	2009-01-01	CATHERINE MCKEOWN	CATHERINE MCKEOWN	2010-07-30

Plan Statistics for PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN

401k plan membership statisitcs for PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN

Measure Date Value
2012: PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 342
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 0
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 0
2011: PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 323
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 323
Number of retired or separated participants receiving benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 323
2009: PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 519
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 771
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 771

Measure	Date	Value
2012: PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	342
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	0
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	0
2011: PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	323
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	323
Number of retired or separated participants receiving benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	323
2009: PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	519
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	771
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	771

Form 5500 Responses for PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN

2012: PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	Yes
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
2011: PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: PEN BAY HEALTHCARE VOLUNTARY BENEFITS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

7743867

Policy instance

Insurance contract or identification number	7743867
Number of Individuals Covered	434
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,378
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
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 $103,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,913
Insurance broker organization code?	3
Insurance broker name	BENEFIT TECHNOLOGIES DIV 9

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

7743867

Policy instance

Insurance contract or identification number	7743867
Number of Individuals Covered	494
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,221
Total amount of fees paid to insurance company	USD $-21
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	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY ACCIDENT
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 $117,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

28997

Policy instance

Insurance contract or identification number	28997
Number of Individuals Covered	358
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,925
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	No
Dental Insurance Welfare Benefit	No
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 $18,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,925
Insurance broker organization code?	3
Insurance broker name	DWIGHT PIERCE

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

128195

Policy instance

Insurance contract or identification number	128195
Number of Individuals Covered	357
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $24,264
Total amount of fees paid to insurance company	USD $303
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	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	Yes
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 $97,052
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,198
Insurance broker organization code?	3
Amount paid for insurance broker fees	303
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker name	MERCER HEALTH AND BENEFITS

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

7743867

Policy instance

Insurance contract or identification number	7743867
Number of Individuals Covered	116
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $20,242
Total amount of fees paid to insurance company	USD $2,722
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	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY ACCIDENT, CRITICAL ILLNESS
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 $175,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,848
Amount paid for insurance broker fees	2274
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH AND BENEFITS

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Company Name:	PEN BAY HEALTHCARE
Employer identification number (EIN):	222494474
NAIC Classification:	622000
NAIC Description:	Hospitals

Jurisdiction of Incorporation:	Maine Bureau of Corporations, Elections & Commissions
Incorporation Date:
Company Identification Number:	19830167ND