401k Plan data: COLUMBUS HOSPICE, INC. BENEFITS PLAN plan

COLUMBUS HOSPICE, INC. BENEFITS PLAN 401k Plan overview

Plan Name	COLUMBUS HOSPICE, INC. BENEFITS PLAN
Plan identification number	504

COLUMBUS HOSPICE, INC. BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

COLUMBUS HOSPICE, INC. has sponsored the creation of one or more 401k plans.

Company Name: COLUMBUS HOSPICE, INC.

Employer identification number (EIN): 581385395

NAIC Classification: 624100
NAIC Description: Individual and Family Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COLUMBUS HOSPICE, INC. BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
504 2021-04-01
504 2018-04-01

Plan Statistics for COLUMBUS HOSPICE, INC. BENEFITS PLAN

401k plan membership statisitcs for COLUMBUS HOSPICE, INC. BENEFITS PLAN

Measure Date Value
2021: COLUMBUS HOSPICE, INC. BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-04-01 131
Total number of active participants reported on line 7a of the Form 5500 2021-04-01 131
Total of all active and inactive participants 2021-04-01 131
Total participants 2021-04-01 131
2018: COLUMBUS HOSPICE, INC. BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-04-01 103
Total number of active participants reported on line 7a of the Form 5500 2018-04-01 123
Total of all active and inactive participants 2018-04-01 123

Measure	Date	Value
2021: COLUMBUS HOSPICE, INC. BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-04-01	131
Total number of active participants reported on line 7a of the Form 5500	2021-04-01	131
Total of all active and inactive participants	2021-04-01	131
Total participants	2021-04-01	131
2018: COLUMBUS HOSPICE, INC. BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-04-01	103
Total number of active participants reported on line 7a of the Form 5500	2018-04-01	123
Total of all active and inactive participants	2018-04-01	123

Form 5500 Responses for COLUMBUS HOSPICE, INC. BENEFITS PLAN

2021: COLUMBUS HOSPICE, INC. BENEFITS PLAN 2021 form 5500 responses
2021-04-01	Type of plan entity	Single employer plan
2021-04-01	Plan funding arrangement – Insurance	Yes
2021-04-01	Plan benefit arrangement – Insurance	Yes
2018: COLUMBUS HOSPICE, INC. BENEFITS PLAN 2018 form 5500 responses
2018-04-01	Type of plan entity	Single employer plan
2018-04-01	Submission has been amended	No
2018-04-01	This submission is the final filing	No
2018-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-04-01	Plan is a collectively bargained plan	No
2018-04-01	Plan funding arrangement – Insurance	Yes
2018-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

Policy instance

Number of Individuals Covered	193
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $13,106
Total amount of fees paid to insurance company	USD $500
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,171
Insurance broker organization code?	3
Amount paid for insurance broker fees	500
Additional information about fees paid to insurance broker	INCENTIVES, EDUCATION, COMMUNICATION AND TRAINING

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

Policy instance

Number of Individuals Covered	131
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00632440

Policy instance

Insurance contract or identification number	00632440
Number of Individuals Covered	130
Insurance policy start date	2021-04-01
Insurance policy end date	2022-03-31
Total amount of commissions paid to insurance broker	USD $64,064
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,088
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD608665

Policy instance

Insurance contract or identification number	SGD608665
Number of Individuals Covered	123
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $3,751
Total amount of fees paid to insurance company	USD $994
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,751
Amount paid for insurance broker fees	994
Additional information about fees paid to insurance broker	SALES & SERVICE OVERRIDE
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

607654

Policy instance

Insurance contract or identification number	607654
Number of Individuals Covered	150
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $51,978
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $350,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,978
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK602026

Policy instance

Insurance contract or identification number	SOK602026
Number of Individuals Covered	123
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

0607654

Policy instance

Insurance contract or identification number	0607654
Number of Individuals Covered	111
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $5,528
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,528
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM603194

Policy instance

Insurance contract or identification number	SGM603194
Number of Individuals Covered	123
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	COLUMBUS HOSPICE, INC.
Employer identification number (EIN):	581385395
NAIC Classification:	624100
NAIC Description:	Individual and Family Services