401k Plan data: HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN plan

HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN 401k Plan overview

Plan Name	HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN
Plan identification number	504

HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

HOSPICE OF THE PIEDMONT, INC. (NC) has sponsored the creation of one or more 401k plans.

Company Name: HOSPICE OF THE PIEDMONT, INC. (NC)

Employer identification number (EIN): 581453827

NAIC Classification: 621610
NAIC Description: Home Health Care Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
504 2020-10-01
504 2019-10-01

Plan Statistics for HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN

401k plan membership statisitcs for HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN

Measure Date Value
2020: HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year 2020-10-01 65
Total number of active participants reported on line 7a of the Form 5500 2020-10-01 56
Number of retired or separated participants receiving benefits 2020-10-01 0
Number of other retired or separated participants entitled to future benefits 2020-10-01 0
Total of all active and inactive participants 2020-10-01 56
2019: HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year 2019-10-01 155
Total number of active participants reported on line 7a of the Form 5500 2019-10-01 154
Number of retired or separated participants receiving benefits 2019-10-01 0
Number of other retired or separated participants entitled to future benefits 2019-10-01 0
Total of all active and inactive participants 2019-10-01 154

Measure	Date	Value
2020: HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year	2020-10-01	65
Total number of active participants reported on line 7a of the Form 5500	2020-10-01	56
Number of retired or separated participants receiving benefits	2020-10-01	0
Number of other retired or separated participants entitled to future benefits	2020-10-01	0
Total of all active and inactive participants	2020-10-01	56
2019: HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year	2019-10-01	155
Total number of active participants reported on line 7a of the Form 5500	2019-10-01	154
Number of retired or separated participants receiving benefits	2019-10-01	0
Number of other retired or separated participants entitled to future benefits	2019-10-01	0
Total of all active and inactive participants	2019-10-01	154

Form 5500 Responses for HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN

2020: HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN 2020 form 5500 responses
2020-10-01	Type of plan entity	Single employer plan
2020-10-01	Submission has been amended	No
2020-10-01	This submission is the final filing	No
2020-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-10-01	Plan is a collectively bargained plan	No
2020-10-01	Plan funding arrangement – Insurance	Yes
2020-10-01	Plan benefit arrangement – Insurance	Yes
2019: HOSPICE OF THE PIEDMONT, INC. GAP MEDICAL PLAN 2019 form 5500 responses
2019-10-01	Type of plan entity	Single employer plan
2019-10-01	First time form 5500 has been submitted	Yes
2019-10-01	Submission has been amended	No
2019-10-01	This submission is the final filing	No
2019-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-10-01	Plan is a collectively bargained plan	No
2019-10-01	Plan funding arrangement – Insurance	Yes
2019-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E5309851

Policy instance

Insurance contract or identification number	E5309851
Number of Individuals Covered	116
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $11,519
Total amount of fees paid to insurance company	USD $323
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?	No
Health Insurance Welfare Benefit	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $72,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,519
Amount paid for insurance broker fees	323
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7711039

Policy instance

Insurance contract or identification number	E7711039
Number of Individuals Covered	108
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-01
Total amount of commissions paid to insurance broker	USD $16,836
Total amount of fees paid to insurance company	USD $683
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?	No
Health Insurance Welfare Benefit	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $96,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,836
Amount paid for insurance broker fees	683
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E5309851

Policy instance

Insurance contract or identification number	E5309851
Number of Individuals Covered	156
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $28,002
Total amount of fees paid to insurance company	USD $2,509
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?	No
Health Insurance Welfare Benefit	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $92,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,002
Amount paid for insurance broker fees	2509
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

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Company Name:	HOSPICE OF THE PIEDMONT, INC. (NC)
Employer identification number (EIN):	581453827
NAIC Classification:	621610
NAIC Description:	Home Health Care Services