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| Plan Name | BLUE SHIELD PPO |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | COMMUNITY PHYSICIANS GROUP, INC. |
| Employer identification number (EIN): | 852554629 |
| 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 | 2023-05-01 | ||||
| 501 | 2023-05-01 | DEBORAH MOFFETT |
| 2023: BLUE SHIELD PPO 2023 form 5500 responses | ||
|---|---|---|
| 2023-05-01 | Type of plan entity | Single employer plan |
| 2023-05-01 | First time form 5500 has been submitted | Yes |
| 2023-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60049 ) | |||||||||||||||||||||||
| Policy contract number | E5615141 | ||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||
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