401k Plan data: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN plan

SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 401k Plan overview

Plan Name	SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN
Plan identification number	504

SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Long-term disability cover

401k Sponsoring company profile

SUSAN B. ALLEN MEMORIAL HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name: SUSAN B. ALLEN MEMORIAL HOSPITAL

Employer identification number (EIN): 480581968

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
504 2015-07-01 GAY KIMBLE GAY KIMBLE 2017-03-16
504 2012-07-01 GAYLE ARNETT GAYLE ARNETT 2014-01-27
504 2011-07-01 GAYLE ARNETT GAYLE ARNETT 2013-01-29
504 2010-07-01 GAYLE ARNETT
504 2009-07-01 GAYLE ARNETT

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
504	2015-07-01	GAY KIMBLE	GAY KIMBLE	2017-03-16
504	2012-07-01	GAYLE ARNETT	GAYLE ARNETT	2014-01-27
504	2011-07-01	GAYLE ARNETT	GAYLE ARNETT	2013-01-29
504	2010-07-01	GAYLE ARNETT
504	2009-07-01	GAYLE ARNETT

Plan Statistics for SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN

401k plan membership statisitcs for SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN

Measure Date Value
2015: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 102
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 88
Number of retired or separated participants receiving benefits 2015-07-01 0
Number of other retired or separated participants entitled to future benefits 2015-07-01 0
Total of all active and inactive participants 2015-07-01 88
2012: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 101
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 91
Number of retired or separated participants receiving benefits 2012-07-01 0
Number of other retired or separated participants entitled to future benefits 2012-07-01 0
Total of all active and inactive participants 2012-07-01 91
2011: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 108
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 100
Total of all active and inactive participants 2011-07-01 100
2010: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2010 401k membership
Total participants, beginning-of-year 2010-07-01 108
Total number of active participants reported on line 7a of the Form 5500 2010-07-01 106
Total of all active and inactive participants 2010-07-01 106
2009: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2009 401k membership
Total participants, beginning-of-year 2009-07-01 110
Total number of active participants reported on line 7a of the Form 5500 2009-07-01 106
Total of all active and inactive participants 2009-07-01 106
Total participants 2009-07-01 106

Measure	Date	Value
2015: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	102
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	88
Number of retired or separated participants receiving benefits	2015-07-01	0
Number of other retired or separated participants entitled to future benefits	2015-07-01	0
Total of all active and inactive participants	2015-07-01	88
2012: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	101
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	91
Number of retired or separated participants receiving benefits	2012-07-01	0
Number of other retired or separated participants entitled to future benefits	2012-07-01	0
Total of all active and inactive participants	2012-07-01	91
2011: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	108
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	100
Total of all active and inactive participants	2011-07-01	100
2010: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2010 401k membership
Total participants, beginning-of-year	2010-07-01	108
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	106
Total of all active and inactive participants	2010-07-01	106
2009: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2009 401k membership
Total participants, beginning-of-year	2009-07-01	110
Total number of active participants reported on line 7a of the Form 5500	2009-07-01	106
Total of all active and inactive participants	2009-07-01	106
Total participants	2009-07-01	106

Form 5500 Responses for SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN

2015: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Submission has been amended	No
2015-07-01	This submission is the final filing	No
2015-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-07-01	Plan is a collectively bargained plan	No
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2012: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Submission has been amended	No
2012-07-01	This submission is the final filing	No
2012-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-07-01	Plan is a collectively bargained plan	No
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2011: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Submission has been amended	No
2011-07-01	This submission is the final filing	No
2011-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-07-01	Plan is a collectively bargained plan	No
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2010: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2010 form 5500 responses
2010-07-01	Type of plan entity	Single employer plan
2010-07-01	Submission has been amended	Yes
2010-07-01	This submission is the final filing	No
2010-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-07-01	Plan is a collectively bargained plan	No
2010-07-01	Plan funding arrangement – Insurance	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes
2009: SUSAN B. ALLEN MEMORIAL HOSPITAL LONG TERM DISABILITY PLAN 2009 form 5500 responses
2009-07-01	Type of plan entity	Single employer plan
2009-07-01	Submission has been amended	No
2009-07-01	This submission is the final filing	No
2009-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-07-01	Plan is a collectively bargained plan	No
2009-07-01	Plan funding arrangement – Insurance	Yes
2009-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VPL 300961

Policy instance

Insurance contract or identification number	VPL 300961
Number of Individuals Covered	75
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,018
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD119541

Policy instance

Insurance contract or identification number	LTD119541
Number of Individuals Covered	22
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,001
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 $12,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1421
Additional information about fees paid to insurance broker	COMMISSION & FEES
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VPL300961

Policy instance

Insurance contract or identification number	VPL300961
Number of Individuals Covered	79
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $0
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	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY DISABILITY INCOME PROTECTION
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 $29,252
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	HARRINGTON BENEFITS SERVICES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD119541

Policy instance

Insurance contract or identification number	LTD119541
Number of Individuals Covered	20
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,282
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VIP530185

Policy instance

Insurance contract or identification number	VIP530185
Number of Individuals Covered	84
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,124
Other welfare benefits provided	VOLUNTARY DISABILITY INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $14,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD119541

Policy instance

Insurance contract or identification number	LTD119541
Number of Individuals Covered	25
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $240
Total amount of fees paid to insurance company	USD $32
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VIP530185

Policy instance

Insurance contract or identification number	VIP530185
Number of Individuals Covered	104
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $3,734
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SUSAN B. ALLEN MEMORIAL HOSPITAL
Employer identification number (EIN):	480581968
NAIC Classification:	622000
NAIC Description:	Hospitals