401k Plan data: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN plan

ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 401k Plan overview

Plan Name	ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN
Plan identification number	005

ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

MERCY HEALTH CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: MERCY HEALTH CORPORATION

Employer identification number (EIN): 472158680

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
005 2023-01-01
005 2022-01-01
005 2021-01-01
005 2020-01-01
005 2019-01-01
005 2018-01-01
005 2017-01-01 KATHY HARRIS

Plan Statistics for ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN

401k plan membership statisitcs for ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN

Measure Date Value
2023: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 211
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 0
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2023-01-01 0
Total participants 2023-01-01 0
Number of participants with account balances 2023-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2023-01-01 0
2022: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 236
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 114
Number of retired or separated participants receiving benefits 2022-01-01 1
Number of other retired or separated participants entitled to future benefits 2022-01-01 95
Total of all active and inactive participants 2022-01-01 210
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 1
Total participants 2022-01-01 211
Number of participants with account balances 2022-01-01 211
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 262
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 131
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 104
Total of all active and inactive participants 2021-01-01 235
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 1
Total participants 2021-01-01 236
Number of participants with account balances 2021-01-01 236
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 289
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 146
Number of retired or separated participants receiving benefits 2020-01-01 1
Number of other retired or separated participants entitled to future benefits 2020-01-01 114
Total of all active and inactive participants 2020-01-01 261
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 1
Total participants 2020-01-01 262
Number of participants with account balances 2020-01-01 262
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 308
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 181
Number of retired or separated participants receiving benefits 2019-01-01 1
Number of other retired or separated participants entitled to future benefits 2019-01-01 106
Total of all active and inactive participants 2019-01-01 288
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 1
Total participants 2019-01-01 289
Number of participants with account balances 2019-01-01 289
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2018: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 348
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 200
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 107
Total of all active and inactive participants 2018-01-01 307
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 1
Total participants 2018-01-01 308
Number of participants with account balances 2018-01-01 308
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 0
2017: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 401
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 211
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 137
Total of all active and inactive participants 2017-01-01 348
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 348
Number of participants with account balances 2017-01-01 334
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0

Measure	Date	Value
2023: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	211
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	0
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2023-01-01	0
Total participants	2023-01-01	0
Number of participants with account balances	2023-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2023-01-01	0
2022: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	236
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	114
Number of retired or separated participants receiving benefits	2022-01-01	1
Number of other retired or separated participants entitled to future benefits	2022-01-01	95
Total of all active and inactive participants	2022-01-01	210
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	1
Total participants	2022-01-01	211
Number of participants with account balances	2022-01-01	211
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	262
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	131
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	104
Total of all active and inactive participants	2021-01-01	235
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	1
Total participants	2021-01-01	236
Number of participants with account balances	2021-01-01	236
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	289
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	146
Number of retired or separated participants receiving benefits	2020-01-01	1
Number of other retired or separated participants entitled to future benefits	2020-01-01	114
Total of all active and inactive participants	2020-01-01	261
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	1
Total participants	2020-01-01	262
Number of participants with account balances	2020-01-01	262
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	308
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	181
Number of retired or separated participants receiving benefits	2019-01-01	1
Number of other retired or separated participants entitled to future benefits	2019-01-01	106
Total of all active and inactive participants	2019-01-01	288
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	1
Total participants	2019-01-01	289
Number of participants with account balances	2019-01-01	289
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2018: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	348
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	200
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	107
Total of all active and inactive participants	2018-01-01	307
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	1
Total participants	2018-01-01	308
Number of participants with account balances	2018-01-01	308
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0
2017: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	401
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	211
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	137
Total of all active and inactive participants	2017-01-01	348
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	348
Number of participants with account balances	2017-01-01	334
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0

Financial Data on ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN

Measure	Date	Value
2022 : ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$-1,744,889
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$1,619,150
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$1,618,850
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$0
Value of total assets at end of year	2022-12-31	$7,212,468
Value of total assets at beginning of year	2022-12-31	$10,576,507
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$300
Total interest from all sources	2022-12-31	$46,232
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$426,760
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2022-12-31	$426,760
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Participant contributions at end of year	2022-12-31	$23,175
Participant contributions at beginning of year	2022-12-31	$13,197
Assets. Other investments not covered elsewhere at end of year	2022-12-31	$19,161
Assets. Other investments not covered elsewhere at beginning of year	2022-12-31	$23,830
Other income not declared elsewhere	2022-12-31	$-1,992
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-3,364,039
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$7,212,468
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$10,576,507
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$5,371,760
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$8,718,273
Interest on participant loans	2022-12-31	$901
Interest earned on other investments	2022-12-31	$45,331
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$1,798,372
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$1,821,207
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-2,215,889
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$1,618,850
Contract administrator fees	2022-12-31	$300
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	WIPFLI LLP
Accountancy firm EIN	2022-12-31	390758449
2021 : ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$1,420,065
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$1,029,485
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$1,029,485
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$0
Value of total assets at end of year	2021-12-31	$10,576,507
Value of total assets at beginning of year	2021-12-31	$10,185,927
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$0
Total interest from all sources	2021-12-31	$40,050
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$692,856
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2021-12-31	$692,856
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Participant contributions at end of year	2021-12-31	$13,197
Participant contributions at beginning of year	2021-12-31	$19,691
Assets. Other investments not covered elsewhere at end of year	2021-12-31	$23,830
Assets. Other investments not covered elsewhere at beginning of year	2021-12-31	$20,126
Other income not declared elsewhere	2021-12-31	$-273
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$390,580
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$10,576,507
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$10,185,927
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$8,718,273
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$7,942,512
Interest on participant loans	2021-12-31	$845
Interest earned on other investments	2021-12-31	$39,205
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$1,821,207
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$2,203,598
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$687,432
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$1,029,485
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	WIPFLI LLP
Accountancy firm EIN	2021-12-31	390758449
2020 : ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$1,428,164
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$1,388,388
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$1,388,388
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$0
Value of total assets at end of year	2020-12-31	$10,185,927
Value of total assets at beginning of year	2020-12-31	$10,146,151
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$0
Total interest from all sources	2020-12-31	$54,316
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$434,648
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2020-12-31	$434,648
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2020-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Participant contributions at end of year	2020-12-31	$19,691
Participant contributions at beginning of year	2020-12-31	$19,707
Assets. Other investments not covered elsewhere at end of year	2020-12-31	$20,126
Assets. Other investments not covered elsewhere at beginning of year	2020-12-31	$17,011
Other income not declared elsewhere	2020-12-31	$-1,471
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$39,776
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$10,185,927
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$10,146,151
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$7,942,512
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$8,008,108
Interest on participant loans	2020-12-31	$1,059
Interest earned on other investments	2020-12-31	$53,257
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$2,203,598
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-12-31	$2,101,325
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$940,671
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$1,388,388
Did the plan have assets held for investment	2020-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Unqualified
Accountancy firm name	2020-12-31	WIPFLI LLP
Accountancy firm EIN	2020-12-31	390758449
2019 : ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$1,777,709
Total income from all sources (including contributions)	2019-12-31	$1,777,709
Total loss/gain on sale of assets	2019-12-31	$0
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$1,003,723
Total of all expenses incurred	2019-12-31	$1,003,723
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$1,003,524
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$1,003,524
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$0
Value of total assets at end of year	2019-12-31	$10,146,151
Value of total assets at end of year	2019-12-31	$10,146,151
Value of total assets at beginning of year	2019-12-31	$9,372,165
Value of total assets at beginning of year	2019-12-31	$9,372,165
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$199
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$199
Total interest from all sources	2019-12-31	$60,914
Total interest from all sources	2019-12-31	$60,914
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$354,261
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$354,261
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2019-12-31	$354,261
Total dividends received from registered investment company shares (eg mutual funds)	2019-12-31	$354,261
Administrative expenses professional fees incurred	2019-12-31	$199
Administrative expenses professional fees incurred	2019-12-31	$199
Was this plan covered by a fidelity bond	2019-12-31	Yes
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2019-12-31	No
If this is an individual account plan, was there a blackout period	2019-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Participant contributions at end of year	2019-12-31	$19,707
Participant contributions at end of year	2019-12-31	$19,707
Participant contributions at beginning of year	2019-12-31	$11,587
Participant contributions at beginning of year	2019-12-31	$11,587
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$773,986
Value of net income/loss	2019-12-31	$773,986
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$10,146,151
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$10,146,151
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$9,372,165
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$9,372,165
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$8,025,119
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$8,025,119
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$7,211,090
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$7,211,090
Interest on participant loans	2019-12-31	$1,141
Interest on participant loans	2019-12-31	$1,141
Interest earned on other investments	2019-12-31	$59,773
Interest earned on other investments	2019-12-31	$59,773
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$2,101,325
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$2,101,325
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$2,149,488
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$2,149,488
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$1,362,534
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$1,362,534
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$1,003,524
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$1,003,524
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	WIPFLI LLP
Accountancy firm name	2019-12-31	WIPFLI LLP
Accountancy firm EIN	2019-12-31	390758449
Accountancy firm EIN	2019-12-31	390758449
2018 : ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total income from all sources (including contributions)	2018-12-31	$-214,401
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$2,116,005
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$2,115,905
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$0
Value of total assets at end of year	2018-12-31	$9,372,165
Value of total assets at beginning of year	2018-12-31	$11,702,571
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$100
Total interest from all sources	2018-12-31	$51,147
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$408,056
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2018-12-31	$408,056
Administrative expenses professional fees incurred	2018-12-31	$100
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Participant contributions at end of year	2018-12-31	$11,587
Participant contributions at beginning of year	2018-12-31	$20,761
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$-2,330,406
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$9,372,165
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$11,702,571
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$7,211,090
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$9,816,182
Interest on participant loans	2018-12-31	$694
Interest earned on other investments	2018-12-31	$50,453
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-12-31	$2,149,488
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-12-31	$1,865,628
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-673,604
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$2,115,905
Did the plan have assets held for investment	2018-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	WIPFLI LLP
Accountancy firm EIN	2018-12-31	390758449
2017 : ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total income from all sources (including contributions)	2017-12-31	$1,869,630
Total loss/gain on sale of assets	2017-12-31	$315
Total of all expenses incurred	2017-12-31	$2,637,772
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$2,637,947
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$0
Value of total assets at end of year	2017-12-31	$11,702,571
Value of total assets at beginning of year	2017-12-31	$12,470,713
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$-175
Total interest from all sources	2017-12-31	$52,408
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$345,098
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2017-12-31	$345,098
Administrative expenses professional fees incurred	2017-12-31	$-175
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$10,000,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Participant contributions at end of year	2017-12-31	$20,761
Participant contributions at beginning of year	2017-12-31	$40,126
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$-768,142
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$11,702,571
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$12,470,713
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2017-12-31	$9,816,182
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-12-31	$10,723,822
Interest on participant loans	2017-12-31	$1,326
Interest earned on other investments	2017-12-31	$50,855
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2017-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2017-12-31	$1,364,860
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2017-12-31	$1,364,860
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2017-12-31	$227
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2017-12-31	$1,865,628
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2017-12-31	$336,774
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-12-31	$1,471,809
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	No
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$2,637,947
Assets. Corporate common stocks other than exployer securities at end of year	2017-12-31	$0
Assets. Corporate common stocks other than exployer securities at beginning of year	2017-12-31	$5,131
Did the plan have assets held for investment	2017-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Aggregate proceeds on sale of assets	2017-12-31	$5,470
Aggregate carrying amount (costs) on sale of assets	2017-12-31	$5,155
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	WIPFLI LLP
Accountancy firm EIN	2017-12-31	390758449

Form 5500 Responses for ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN

2023: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Submission has been amended	No
2023-01-01	This submission is the final filing	Yes
2023-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2023-01-01	Plan is a collectively bargained plan	No
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – Trust	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement - Trust	Yes
2022: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
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 funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: ROCKFORD MEMORIAL HOSPITAL SUPPLEMENTAL PENSION PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

664140

Policy instance

Insurance contract or identification number	664140
Number of Individuals Covered	213
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $18,601
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?	Yes
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 $18,601
Insurance broker organization code?	3

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

664140

Policy instance

Insurance contract or identification number	664140
Number of Individuals Covered	238
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,410
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?	Yes
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 $4,410
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

710810/806623

Policy instance

Insurance contract or identification number	710810/806623
Number of Individuals Covered	0
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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?	Yes
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

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

664140

Policy instance

Insurance contract or identification number	664140
Number of Individuals Covered	264
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,226
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?	Yes
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 $4,226
Insurance broker organization code?	3

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

664140

Policy instance

Insurance contract or identification number	664140
Number of Individuals Covered	291
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,391
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?	Yes
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 $4,391
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	ALLOCATED NON-CASH COMP
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

710810-806623

Policy instance

Insurance contract or identification number	710810-806623
Number of Individuals Covered	7
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
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?	Yes
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

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

710810-806623

Policy instance

Insurance contract or identification number	710810-806623
Number of Individuals Covered	8
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
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?	Yes
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

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

664140

Policy instance

Insurance contract or identification number	664140
Number of Individuals Covered	310
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $23,909
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?	Yes
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 $23,909
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	ALLOCATED NON-CASH COMP
Insurance broker organization code?	3

VOYA RETIRIEMENT INSURANCE AND ANNUITY COMPANY (National Association of Insurance Commissioners NAIC id number: 86509 )

Policy contract number

664140

Policy instance

Insurance contract or identification number	664140
Number of Individuals Covered	339
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,252
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?	Yes
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 $4,252
Insurance broker organization code?	3
Insurance broker name	REGULUS ADVISORS, LLC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

710810/806623

Policy instance

Insurance contract or identification number	710810/806623
Number of Individuals Covered	10
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $210
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?	Yes
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 $0
Amount paid for insurance broker fees	210
Additional information about fees paid to insurance broker	REFERRAL/SERVICE FEE
Insurance broker organization code?	3
Insurance broker name	FIDELITY INVESTMENTS TAX-EXEMPT SVC

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Company Name:	MERCY HEALTH CORPORATION
Employer identification number (EIN):	472158680
NAIC Classification:	622000
NAIC Description:	Hospitals