401k Plan data: THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN plan

THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 401k Plan overview

Plan Name	THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN
Plan identification number	002

THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

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.
Code section 403(b)(1) arrangement - See Limited Pension Plan Reporting instructions for Code section 403(b)(1) arrangements for certain exempt organizations.
Code section 403(b)(7) accounts - See Limited Pension Plan Reporting instructions for Code section 403(b)(7) custodial accounts for regulated investment company stock for certain exempt organizations.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

BON SECOURS-ST. FRANCIS XAVIER HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name: BON SECOURS-ST. FRANCIS XAVIER HOSPITAL

Employer identification number (EIN): 571067254

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2013-01-01 CHRISTIE CLERC 2014-07-14
002 2012-01-01 CHRISTIE CLERC 2013-04-17 HOWARD DOUGLAS HARRISON 2013-04-17
002 2011-01-01 CHRISTIE CLERC HOWARD DOUGLAS HARRISON 2012-07-02
002 2010-01-01 CHRISTIE CLERC HOWARD DOUGLAS HARRISON 2011-07-20
002 2009-01-01 CHRISTIE CLERC DOUG HARRISON 2010-07-23

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
002	2013-01-01	CHRISTIE CLERC	2014-07-14
002	2012-01-01	CHRISTIE CLERC	2013-04-17	HOWARD DOUGLAS HARRISON	2013-04-17
002	2011-01-01	CHRISTIE CLERC		HOWARD DOUGLAS HARRISON	2012-07-02
002	2010-01-01	CHRISTIE CLERC		HOWARD DOUGLAS HARRISON	2011-07-20
002	2009-01-01	CHRISTIE CLERC		DOUG HARRISON	2010-07-23

Plan Statistics for THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN

401k plan membership statisitcs for THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN

Measure Date Value
2011: THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 106
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 96
Number of retired or separated participants receiving benefits 2011-01-01 1
Number of other retired or separated participants entitled to future benefits 2011-01-01 1
Total of all active and inactive participants 2011-01-01 98
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 3
Total participants 2011-01-01 101
Number of participants with account balances 2011-01-01 101
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2010: THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 103
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 1
Total of all active and inactive participants 2010-01-01 104
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 2
Total participants 2010-01-01 106
Number of participants with account balances 2010-01-01 106
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 113
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 108
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 108
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 2
Total participants 2009-01-01 110
Number of participants with account balances 2009-01-01 110
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2011: THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	106
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	96
Number of retired or separated participants receiving benefits	2011-01-01	1
Number of other retired or separated participants entitled to future benefits	2011-01-01	1
Total of all active and inactive participants	2011-01-01	98
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	3
Total participants	2011-01-01	101
Number of participants with account balances	2011-01-01	101
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2010: THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	103
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	1
Total of all active and inactive participants	2010-01-01	104
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	2
Total participants	2010-01-01	106
Number of participants with account balances	2010-01-01	106
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	113
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	108
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	108
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	2
Total participants	2009-01-01	110
Number of participants with account balances	2009-01-01	110
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN

Measure	Date	Value
2011 : THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2011 401k financial data
Total income from all sources	2011-12-31	$41,885
Expenses. Total of all expenses incurred	2011-12-31	$115,985
Benefits paid (including direct rollovers)	2011-12-31	$114,413
Total plan assets at end of year	2011-12-31	$1,396,129
Total plan assets at beginning of year	2011-12-31	$1,470,229
Value of fidelity bond covering the plan	2011-12-31	$500,000
Other income received	2011-12-31	$41,885
Net income (gross income less expenses)	2011-12-31	$-74,100
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$1,396,129
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$1,470,229
Assets. Value of participant loans	2011-12-31	$7,312
Expenses. Administrative service providers (salaries,fees and commissions)	2011-12-31	$1,572
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
2010 : THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2010 401k financial data
Total income from all sources	2010-12-31	$70,596
Expenses. Total of all expenses incurred	2010-12-31	$24,827
Benefits paid (including direct rollovers)	2010-12-31	$23,715
Total plan assets at end of year	2010-12-31	$1,470,229
Total plan assets at beginning of year	2010-12-31	$1,424,460
Value of fidelity bond covering the plan	2010-12-31	$500,000
Expenses. Other expenses not covered elsewhere	2010-12-31	$1,112
Other income received	2010-12-31	$70,596
Net income (gross income less expenses)	2010-12-31	$45,769
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$1,470,229
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$1,424,460
Assets. Value of participant loans	2010-12-31	$721
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
2009 : THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN

2011: THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: THE BON SECOURS-ST. FRANCIS XAVIER HOSPITAL EMPLOYEE TAX DEFERRED ANNUITY PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70688 )

Policy contract number

FA067660

Policy instance

Insurance contract or identification number	FA067660
Number of Individuals Covered	101
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,250
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70688 )

Policy contract number

FA067660

Policy instance

Insurance contract or identification number	FA067660
Number of Individuals Covered	106
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	BON SECOURS-ST. FRANCIS XAVIER HOSPITAL
Employer identification number (EIN):	571067254
NAIC Classification:	622000
NAIC Description:	Hospitals