401k Plan data: HOSPITAL SAN JUAN CAPESTRANO

HOSPITAL SAN JUAN CAPESTRANO - HEALTH PLAN 401k Plan overview

Plan Name	HOSPITAL SAN JUAN CAPESTRANO - HEALTH PLAN
Plan identification number	501

HOSPITAL SAN JUAN CAPESTRANO - HEALTH PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	SELECT distinct(Description) AS Description FROM 401k_benefit_codes LEFT JOIN 401k_benefit_code_description ON BenefitCode=Code COLLATE utf8_unicode_ci WHERE EIN='660771568' AND PlanID='501'

401k Sponsoring company profile

SAN JUAN CAPESTRANO HOSPITAL, INC has sponsored the creation of one or more 401k plans.

Company Name: SAN JUAN CAPESTRANO HOSPITAL, INC

Employer identification number (EIN): 660771568

NAIC Classification: 621420
NAIC Description: Outpatient Mental Health and Substance Abuse Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOSPITAL SAN JUAN CAPESTRANO - HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2024-01-01 ODETTE BURGOS
501 2023-01-01
501 2023-01-01 LORAINE RIVERA
501 2022-01-01
501 2022-01-01 LORAINE RIVERA
501 2021-01-01
501 2021-01-01 LORAINE RIVERA
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 MARTHA GAY
501 2016-01-01 MARTHA GAY
501 2015-01-01 MARTHA GAY
501 2014-01-01 MARTHA GAY
501 2013-01-01 MARTHA GAY
501 2012-01-01 JOSE DAVILA

Insurance Providers Used on plan

FIRST MEDICAL HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95722 )

Policy contract number

2275, 2276

Policy instance

Insurance contract or identification number	2275, 2276
Number of Individuals Covered	228
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $43,257
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	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
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

FIRST MEDICAL HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95722 )

Policy contract number

2275,2276

Policy instance

Insurance contract or identification number	2275,2276
Number of Individuals Covered	228
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $38,907
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	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
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

FIRST MEDICAL HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95722 )

Policy contract number

2275,2276

Policy instance

FIRST MEDICAL HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95722 )

Policy contract number

2275,2276

Policy instance

TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )

Policy contract number

55816

Policy instance

TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )

Policy contract number

SP0003376

Policy instance

TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )

Policy contract number

SP0003376

Policy instance

Potentially related plans

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Company Name:	SAN JUAN CAPESTRANO HOSPITAL, INC
Employer identification number (EIN):	660771568
NAIC Classification:	621420
NAIC Description:	Outpatient Mental Health and Substance Abuse Centers

Plan id#	Filing Submission Date	Name of Administrator
501	2024-01-01	ODETTE BURGOS
501	2023-01-01
501	2023-01-01	LORAINE RIVERA
501	2022-01-01
501	2022-01-01	LORAINE RIVERA
501	2021-01-01
501	2021-01-01	LORAINE RIVERA
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	MARTHA GAY
501	2016-01-01	MARTHA GAY
501	2015-01-01	MARTHA GAY
501	2014-01-01	MARTHA GAY
501	2013-01-01	MARTHA GAY
501	2012-01-01	JOSE DAVILA