401k Plan data: LBUCC MASTER BENEFIT PLAN plan

LBUCC MASTER BENEFIT PLAN 401k Plan overview

Plan Name	LBUCC MASTER BENEFIT PLAN
Plan identification number	510

LBUCC MASTER BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

LOS BARRIOS UNIDOS COMMUNITY CLINIC, INC. has sponsored the creation of one or more 401k plans.

Company Name: LOS BARRIOS UNIDOS COMMUNITY CLINIC, INC.

Employer identification number (EIN): 751378664

NAIC Classification: 621112
NAIC Description: Offices of Physicians, Mental Health Specialists

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LBUCC MASTER BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
510 2015-01-01 DEBRA GLORIA
510 2012-01-01 LEONOR MARQUEZ

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
510	2015-01-01	DEBRA GLORIA
510	2012-01-01	LEONOR MARQUEZ

Plan Statistics for LBUCC MASTER BENEFIT PLAN

401k plan membership statisitcs for LBUCC MASTER BENEFIT PLAN

Measure Date Value
2015: LBUCC MASTER BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 122
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 164
Number of retired or separated participants receiving benefits 2015-01-01 1
Total of all active and inactive participants 2015-01-01 165
Total participants 2015-01-01 165
2012: LBUCC MASTER BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 105
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 121
Number of retired or separated participants receiving benefits 2012-01-01 1
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 122
Total participants 2012-01-01 122

Measure	Date	Value
2015: LBUCC MASTER BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	122
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	164
Number of retired or separated participants receiving benefits	2015-01-01	1
Total of all active and inactive participants	2015-01-01	165
Total participants	2015-01-01	165
2012: LBUCC MASTER BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	105
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	121
Number of retired or separated participants receiving benefits	2012-01-01	1
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	122
Total participants	2012-01-01	122

Form 5500 Responses for LBUCC MASTER BENEFIT PLAN

2015: LBUCC MASTER BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2012: LBUCC MASTER BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	First time form 5500 has been submitted	Yes
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KM05989272

Policy instance

Insurance contract or identification number	KM05989272
Number of Individuals Covered	164
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,187
Are there contracts with allocated funds for individual policies?	No
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	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
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 $10,187
Insurance broker organization code?	3
Insurance broker name	JOHN VERNON HEATH

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

036271

Policy instance

Insurance contract or identification number	036271
Number of Individuals Covered	164
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $86,554
Are there contracts with allocated funds for individual policies?	No
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 $49,712
Insurance broker organization code?	3
Amount paid for insurance broker fees	1404
Additional information about fees paid to insurance broker	SPECIAL PROGRAM
Insurance broker name	JOHN VERNON HEATH

Potentially related plans

LBUCC MASTER BENEFIT PLAN [EIN = 751378665]

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Company Name:	LOS BARRIOS UNIDOS COMMUNITY CLINIC, INC.
Employer identification number (EIN):	751378664
NAIC Classification:	621112
NAIC Description:	Offices of Physicians, Mental Health Specialists