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| Plan Name | BLACKSTONE MEDICAL SERVICES WELLFARE BENEFIT PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | BLACKSTONE MEDICAL SERVICES, LLC CITY OF WASHINGTON |
| Employer identification number (EIN): | 900634405 |
| NAIC Classification: | 541990 |
| NAIC Description: | All Other Professional, Scientific, and Technical Services |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2023-07-01 | VICK TIPNES | |||
| 501 | 2022-07-01 | ||||
| 501 | 2022-07-01 | VICK TIPNES |
| 2022: BLACKSTONE MEDICAL SERVICES WELLFARE BENEFIT PLAN 2022 form 5500 responses | ||
|---|---|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | First time form 5500 has been submitted | Yes |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 ) | |
| Policy contract number | EMCL2100155002 |
| Policy instance | 1 |
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) | |
| Policy contract number | HCCLOT41214 |
| Policy instance | 2 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |
| Policy contract number | 00558235 |
| Policy instance | 3 |
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