401k Plan data: ESCAMBIA COUNTY HEALTH CARE AUTHORITY (CRITICAL ILLNESS) plan

ESCAMBIA COUNTY HEALTH CARE AUTHORITY (CRITICAL ILLNESS) 401k Plan overview

Plan Name	ESCAMBIA COUNTY HEALTH CARE AUTHORITY (CRITICAL ILLNESS)
Plan identification number	507

ESCAMBIA COUNTY HEALTH CARE AUTHORITY (CRITICAL ILLNESS) Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision)

401k Sponsoring company profile

KIMBERLY J. WESTERMANN, D.M.D. has sponsored the creation of one or more 401k plans.

Company Name: KIMBERLY J. WESTERMANN, D.M.D.

Employer identification number (EIN): 611143638

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ESCAMBIA COUNTY HEALTH CARE AUTHORITY (CRITICAL ILLNESS)

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
507 2022-01-01

Plan Statistics for ESCAMBIA COUNTY HEALTH CARE AUTHORITY (CRITICAL ILLNESS)

401k plan membership statisitcs for ESCAMBIA COUNTY HEALTH CARE AUTHORITY (CRITICAL ILLNESS)

Measure Date Value
2022: ESCAMBIA COUNTY HEALTH CARE AUTHORITY (CRITICAL ILLNESS) 2022 401k membership
Total participants, beginning-of-year 2022-01-01 37
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 37
Total of all active and inactive participants 2022-01-01 37
Total participants 2022-01-01 37

Measure	Date	Value
2022: ESCAMBIA COUNTY HEALTH CARE AUTHORITY (CRITICAL ILLNESS) 2022 401k membership
Total participants, beginning-of-year	2022-01-01	37
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	37
Total of all active and inactive participants	2022-01-01	37
Total participants	2022-01-01	37

Form 5500 Responses for ESCAMBIA COUNTY HEALTH CARE AUTHORITY (CRITICAL ILLNESS)

2022: ESCAMBIA COUNTY HEALTH CARE AUTHORITY (CRITICAL ILLNESS) 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

887012G

Policy instance

Insurance contract or identification number	887012G
Number of Individuals Covered	37
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,004
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,004
Insurance broker organization code?	3

Potentially related plans

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Company Name:	KIMBERLY J. WESTERMANN, D.M.D.
Employer identification number (EIN):	611143638
NAIC Classification:	622000
NAIC Description:	Hospitals