HMO ILLINOIS
|
2009
|
360724690
|
2010-10-13
|
AMERICAN DENTAL ASSOCIATION
|
113
|
|
File |
View Page
|
Three-digit plan number (PN) |
509
|
Effective date of plan |
1986-01-01
|
Business code |
813000
|
Sponsor’s telephone number |
3124402538
|
Plan sponsor’s mailing address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611
|
Plan sponsor’s
address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611
|
Plan administrator’s name and address
Administrator’s EIN |
360724690 |
Plan administrator’s name |
AMERICAN DENTAL ASSOCIATION |
Plan administrator’s
address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611 |
Administrator’s telephone number |
3124402538 |
Number of participants as of the end of the plan year
Active participants |
119 |
Retired or separated participants receiving
benefits |
15 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2010-10-13 |
Name of individual signing |
PAMELA DISSELHORST |
Valid signature |
Filed with authorized/valid electronic signature |
|
Role |
Employer/plan sponsor |
Date |
2010-10-13 |
Name of individual signing |
PAMELA DISSELHORST |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
KAISER PERMANENTE HMO
|
2009
|
360724690
|
2010-10-13
|
AMERICAN DENTAL ASSOCIATION
|
25
|
|
File |
View Page
|
Three-digit plan number (PN) |
507
|
Effective date of plan |
1982-01-01
|
Business code |
813000
|
Sponsor’s telephone number |
3124402538
|
Plan sponsor’s mailing address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611
|
Plan sponsor’s
address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611
|
Plan administrator’s name and address
Administrator’s EIN |
360724690 |
Plan administrator’s name |
AMERICAN DENTAL ASSOCIATION |
Plan administrator’s
address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611 |
Administrator’s telephone number |
3124402538 |
Number of participants as of the end of the plan year
Active participants |
19 |
Retired or separated participants receiving
benefits |
9 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2010-10-13 |
Name of individual signing |
PAMELA DISSELHORST |
Valid signature |
Filed with authorized/valid electronic signature |
|
Role |
Employer/plan sponsor |
Date |
2010-10-13 |
Name of individual signing |
PAMELA DISSELHORST |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
COMPREHENSIVE MAJOR MEDICAL PLAN
|
2009
|
360724690
|
2010-10-12
|
AMERICAN DENTAL ASSOCIATION
|
304
|
|
File |
View Page
|
Three-digit plan number (PN) |
503
|
Effective date of plan |
1983-03-15
|
Business code |
813000
|
Sponsor’s telephone number |
3124402538
|
Plan sponsor’s mailing address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611
|
Plan sponsor’s
address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611
|
Plan administrator’s name and address
Administrator’s EIN |
360724690 |
Plan administrator’s name |
AMERICAN DENTAL ASSOCIATION |
Plan administrator’s
address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611 |
Administrator’s telephone number |
3124402538 |
Number of participants as of the end of the plan year
Active participants |
231 |
Retired or separated participants receiving
benefits |
85 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2010-10-12 |
Name of individual signing |
PAMELA DISSELHORST |
Valid signature |
Filed with authorized/valid electronic signature |
|
Role |
Employer/plan sponsor |
Date |
2010-10-12 |
Name of individual signing |
PAMELA DISSELHORST |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
CAREFIRST HMO
|
2009
|
360724690
|
2010-10-13
|
AMERICAN DENTAL ASSOCIATION
|
16
|
|
File |
View Page
|
Three-digit plan number (PN) |
506
|
Effective date of plan |
1987-01-01
|
Business code |
813000
|
Sponsor’s telephone number |
3124402538
|
Plan sponsor’s mailing address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611
|
Plan sponsor’s
address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611
|
Plan administrator’s name and address
Administrator’s EIN |
360724690 |
Plan administrator’s name |
AMERICAN DENTAL ASSOCIATION |
Plan administrator’s
address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611 |
Administrator’s telephone number |
3124402538 |
Number of participants as of the end of the plan year
Active participants |
21 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2010-10-13 |
Name of individual signing |
PAMELA DISSELHORST |
Valid signature |
Filed with authorized/valid electronic signature |
|
Role |
Employer/plan sponsor |
Date |
2010-10-13 |
Name of individual signing |
PAMELA DISSELHORST |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
TRAVEL-ACCIDENT INSURANCE (AD&D INSURANCE)
|
2009
|
360724690
|
2010-10-12
|
AMERICAN DENTAL ASSOCIATION
|
473
|
|
File |
View Page
|
Three-digit plan number (PN) |
504
|
Effective date of plan |
1986-01-01
|
Business code |
813000
|
Sponsor’s telephone number |
3124402538
|
Plan sponsor’s mailing address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611
|
Plan sponsor’s
address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611
|
Plan administrator’s name and address
Administrator’s EIN |
360724690 |
Plan administrator’s name |
AMERICAN DENTAL ASSOCIATION |
Plan administrator’s
address |
211 EAST CHICAGO AVENUE, CHICAGO, IL, 60611 |
Administrator’s telephone number |
3124402538 |
Number of participants as of the end of the plan year
Active participants |
472 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2010-10-12 |
Name of individual signing |
PAMELA DISSELHORST |
Valid signature |
Filed with authorized/valid electronic signature |
|
Role |
Employer/plan sponsor |
Date |
2010-10-12 |
Name of individual signing |
PAMELA DISSELHORST |
Valid signature |
Filed with authorized/valid electronic signature |
|
|