| Plan Name | WASHINGTON COUNTY HOSPITAL BENEFIT PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
|
| Company Name: | WASHINGTON COUNTY HOSPITAL |
| Employer identification number (EIN): | 376020408 |
| NAIC Classification: | 622000 |
| NAIC Description: | Hospitals |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2020-01-01 |
| 2020: WASHINGTON COUNTY HOSPITAL BENEFIT PLAN 2020 form 5500 responses | ||
|---|---|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | First time form 5500 has been submitted | Yes |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) | |
| Policy contract number | PK1169 PK1170 |
| Policy instance | 1 |
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) | |
| Policy contract number | 36644 |
| Policy instance | 2 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) | |
| Policy contract number | 30088555 |
| Policy instance | 3 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) | |
| Policy contract number | 97809 |
| Policy instance | 4 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 0000 ) | |
| Policy contract number | 5933531 |
| Policy instance | 5 |