401k Plan data: PENNSYLVANIA AMBULANCE, LLC GROUP INSURANCE PLAN plan

PENNSYLVANIA AMBULANCE, LLC GROUP INSURANCE PLAN 401k Plan overview

Plan Name	PENNSYLVANIA AMBULANCE, LLC GROUP INSURANCE PLAN
Plan identification number	502

PENNSYLVANIA AMBULANCE, LLC GROUP INSURANCE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Dental Vision Temporary disability (accident and sickness) Other welfare benefit cover Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

PENNSYLVANIA AMBULANCE has sponsored the creation of one or more 401k plans.

Company Name: PENNSYLVANIA AMBULANCE

Employer identification number (EIN): 462961683

NAIC Classification: 621399
NAIC Description: Offices of All Other Miscellaneous Health Practitioners

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PENNSYLVANIA AMBULANCE, LLC GROUP INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2021-08-31

Plan Statistics for PENNSYLVANIA AMBULANCE, LLC GROUP INSURANCE PLAN

401k plan membership statisitcs for PENNSYLVANIA AMBULANCE, LLC GROUP INSURANCE PLAN

Measure Date Value
2021: PENNSYLVANIA AMBULANCE, LLC GROUP INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-08-31 60
Total number of active participants reported on line 7a of the Form 5500 2021-08-31 68
Number of retired or separated participants receiving benefits 2021-08-31 0
Number of other retired or separated participants entitled to future benefits 2021-08-31 0
Total of all active and inactive participants 2021-08-31 68

Measure	Date	Value
2021: PENNSYLVANIA AMBULANCE, LLC GROUP INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-08-31	60
Total number of active participants reported on line 7a of the Form 5500	2021-08-31	68
Number of retired or separated participants receiving benefits	2021-08-31	0
Number of other retired or separated participants entitled to future benefits	2021-08-31	0
Total of all active and inactive participants	2021-08-31	68

Form 5500 Responses for PENNSYLVANIA AMBULANCE, LLC GROUP INSURANCE PLAN

2021: PENNSYLVANIA AMBULANCE, LLC GROUP INSURANCE PLAN 2021 form 5500 responses
2021-08-31	Type of plan entity	Single employer plan
2021-08-31	First time form 5500 has been submitted	Yes
2021-08-31	Submission has been amended	No
2021-08-31	This submission is the final filing	No
2021-08-31	This return/report is a short plan year return/report (less than 12 months)	No
2021-08-31	Plan is a collectively bargained plan	No
2021-08-31	Plan funding arrangement – Insurance	Yes
2021-08-31	Plan funding arrangement – General assets of the sponsor	Yes
2021-08-31	Plan benefit arrangement – Insurance	Yes
2021-08-31	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

2178

Policy instance

Insurance contract or identification number	2178
Number of Individuals Covered	56
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-30
Total amount of commissions paid to insurance broker	USD $260
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	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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $260
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	NONE
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

0042929

Policy instance

Insurance contract or identification number	0042929
Number of Individuals Covered	68
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-30
Total amount of commissions paid to insurance broker	USD $3,234
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	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 $42,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,234
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	NONE
Insurance broker organization code?	3

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Company Name:	PENNSYLVANIA AMBULANCE
Employer identification number (EIN):	462961683
NAIC Classification:	621399
NAIC Description:	Offices of All Other Miscellaneous Health Practitioners