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| Plan Name | SUBSERO HEALTH, LLC WELFARE BENEFIT PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | SUBSERO CARE, LLC DBA SUBSERO HEALTH |
| Employer identification number (EIN): | 822912515 |
| NAIC Classification: | 621111 |
| NAIC Description: | Offices of Physicians (except Mental Health Specialists) |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2020-08-01 | ||||
| 501 | 2019-08-01 |
| Measure | Date | Value |
|---|---|---|
| 2020: SUBSERO HEALTH, LLC WELFARE BENEFIT PLAN 2020 401k membership | ||
| Total participants, beginning-of-year | 2020-08-01 | 240 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-08-01 | 240 |
| Number of retired or separated participants receiving benefits | 2020-08-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2020-08-01 | 0 |
| Total of all active and inactive participants | 2020-08-01 | 242 |
| 2019: SUBSERO HEALTH, LLC WELFARE BENEFIT PLAN 2019 401k membership | ||
| Total participants, beginning-of-year | 2019-08-01 | 197 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-08-01 | 182 |
| Number of retired or separated participants receiving benefits | 2019-08-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2019-08-01 | 0 |
| Total of all active and inactive participants | 2019-08-01 | 184 |
| 2020: SUBSERO HEALTH, LLC WELFARE BENEFIT PLAN 2020 form 5500 responses | ||
|---|---|---|
| 2020-08-01 | Type of plan entity | Single employer plan |
| 2020-08-01 | Submission has been amended | No |
| 2020-08-01 | This submission is the final filing | No |
| 2020-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-08-01 | Plan is a collectively bargained plan | No |
| 2020-08-01 | Plan funding arrangement – Insurance | Yes |
| 2020-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: SUBSERO HEALTH, LLC WELFARE BENEFIT PLAN 2019 form 5500 responses | ||
| 2019-08-01 | Type of plan entity | Single employer plan |
| 2019-08-01 | First time form 5500 has been submitted | Yes |
| 2019-08-01 | Submission has been amended | No |
| 2019-08-01 | This submission is the final filing | No |
| 2019-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-08-01 | Plan is a collectively bargained plan | No |
| 2019-08-01 | Plan funding arrangement – Insurance | Yes |
| 2019-08-01 | Plan benefit arrangement – Insurance | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 00513217 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | B2343 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | B2343 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 3 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 00513217 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | B2343 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | B2343 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 3 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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