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| Plan Name | DOCTORS COMMUNITY HOSPITAL EMPLOYEE BENEFITS PLANS 1, 2, AND 3 |
| Plan identification number | 510 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | LUMINIS HEALTH DOCTOR'S COMMUNITY MEDICAL CENTER |
| Employer identification number (EIN): | 521638026 |
| NAIC Classification: | 622000 |
| NAIC Description: | Hospitals |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 510 | 2021-01-01 | ||||
| 510 | 2021-01-01 | CHRISTIAN SOROCHTY | |||
| 510 | 2020-01-01 | ||||
| 510 | 2019-01-01 | ||||
| 510 | 2017-01-01 | CAMILLE R. BASH |
| Measure | Date | Value |
|---|---|---|
| 2021: DOCTORS COMMUNITY HOSPITAL EMPLOYEE BENEFITS PLANS 1, 2, AND 3 2021 401k membership | ||
| Total participants, beginning-of-year | 2021-01-01 | 20 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 0 |
| 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 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 0 |
| 2020: DOCTORS COMMUNITY HOSPITAL EMPLOYEE BENEFITS PLANS 1, 2, AND 3 2020 401k membership | ||
| Total participants, beginning-of-year | 2020-01-01 | 53 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 19 |
| 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 | 1 |
| Total of all active and inactive participants | 2020-01-01 | 21 |
| 2019: DOCTORS COMMUNITY HOSPITAL EMPLOYEE BENEFITS PLANS 1, 2, AND 3 2019 401k membership | ||
| Total participants, beginning-of-year | 2019-01-01 | 79 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 78 |
| 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 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 79 |
| 2017: DOCTORS COMMUNITY HOSPITAL EMPLOYEE BENEFITS PLANS 1, 2, AND 3 2017 401k membership | ||
| Total participants, beginning-of-year | 2017-01-01 | 71 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 92 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 97 |
| 2021: DOCTORS COMMUNITY HOSPITAL EMPLOYEE BENEFITS PLANS 1, 2, AND 3 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 | Yes |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: DOCTORS COMMUNITY HOSPITAL EMPLOYEE BENEFITS PLANS 1, 2, AND 3 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 – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: DOCTORS COMMUNITY HOSPITAL EMPLOYEE BENEFITS PLANS 1, 2, AND 3 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 – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: DOCTORS COMMUNITY HOSPITAL EMPLOYEE BENEFITS PLANS 1, 2, AND 3 2017 form 5500 responses | ||
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | First time form 5500 has been submitted | Yes |
| 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 – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) | |
| Policy contract number | 50081 |
| Policy instance | 8 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) | |
| Policy contract number | 12159781 |
| Policy instance | 1 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) | |
| Policy contract number | 52684 |
| Policy instance | 2 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) | |
| Policy contract number | R0301119 |
| Policy instance | 3 |
| UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 ) | |
| Policy contract number | 12555 |
| Policy instance | 4 |
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) | |
| Policy contract number | 66987 |
| Policy instance | 5 |
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) | |
| Policy contract number | SDPSCHAJ |
| Policy instance | 6 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) | |
| Policy contract number | 8862112 |
| Policy instance | 7 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) | |
| Policy contract number | 52684 |
| Policy instance | 2 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) | |
| Policy contract number | R0301119 |
| Policy instance | 3 |
| UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 ) | |
| Policy contract number | 12555 |
| Policy instance | 4 |
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) | |
| Policy contract number | 66987 |
| Policy instance | 5 |
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) | |
| Policy contract number | SDPSCHAJ |
| Policy instance | 6 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) | |
| Policy contract number | 8862112 |
| Policy instance | 7 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) | |
| Policy contract number | 50081 |
| Policy instance | 8 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) | |
| Policy contract number | 12159781 |
| Policy instance | 1 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) | |
| Policy contract number | 50081 |
| Policy instance | 8 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) | |
| Policy contract number | 8862112 |
| Policy instance | 7 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) | |
| Policy contract number | 12159781 |
| Policy instance | 1 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) | |
| Policy contract number | 52684 |
| Policy instance | 2 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) | |
| Policy contract number | R0301119 |
| Policy instance | 3 |
| UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 ) | |
| Policy contract number | 12555 |
| Policy instance | 4 |
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) | |
| Policy contract number | 66987 |
| Policy instance | 5 |
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) | |
| Policy contract number | SDPSCHAJ |
| Policy instance | 6 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) | |
| Policy contract number | 52684 |
| Policy instance | 2 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) | |
| Policy contract number | R0301119 |
| Policy instance | 3 |
| UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 ) | |
| Policy contract number | 12555 |
| Policy instance | 4 |
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) | |
| Policy contract number | 66987 |
| Policy instance | 5 |
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) | |
| Policy contract number | SDPSCHA |
| Policy instance | 6 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) | |
| Policy contract number | 8862112 |
| Policy instance | 7 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) | |
| Policy contract number | 50081 |
| Policy instance | 8 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) | |
| Policy contract number | 52684 |
| Policy instance | 9 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) | |
| Policy contract number | 12159781 |
| Policy instance | 1 |
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