401k Plan data: CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN plan

CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN 401k Plan overview

Plan Name	CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN
Plan identification number	503

CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN Benefits

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

401k Sponsoring company profile

CLEVER CARE HEALTH PLAN INC. has sponsored the creation of one or more 401k plans.

Company Name: CLEVER CARE HEALTH PLAN INC.

Employer identification number (EIN): 832354214

NAIC Classification: 524140

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2023-01-01 RICHARD GREENE 2024-08-02
503 2022-01-01 RICHARD GREENE 2024-05-15

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
503	2023-01-01	RICHARD GREENE	2024-08-02
503	2022-01-01	RICHARD GREENE	2024-05-15

Plan Statistics for CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN

401k plan membership statisitcs for CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN

Measure Date Value
2023: CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 0
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 0
2022: CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 147
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 147

Measure	Date	Value
2023: CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	0
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	0
2022: CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	147
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	147

Form 5500 Responses for CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN

2023: CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Submission has been amended	No
2023-01-01	This submission is the final filing	Yes
2023-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-01-01	Plan is a collectively bargained plan	No
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: CLEVER CARE HEALTH PLAN INC. MEDICAL PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	First time form 5500 has been submitted	Yes
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

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

927831

Policy instance

Insurance contract or identification number	927831
Number of Individuals Covered	212
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $45,993
Total amount of fees paid to insurance company	USD $0
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 $657,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,852
Insurance broker organization code?	3

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Company Name:	CLEVER CARE HEALTH PLAN INC.
Employer identification number (EIN):	832354214
NAIC Classification:	524140