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Lan endowment? ' <br /> b . If YES , what was the current estimated value on 12/31 / 2002 ? $ 0 <br /> 4. FOUNDATION <br /> a . Does your organization have a separate Foundation ? <br /> C Yes No <br /> b . What was the current estimated value of the Foundation 's Assets on $ 0 <br /> 12/31/ 2002? <br /> c . Are the Assets of the Foundation reported under Section A (Value of r <br /> All Assets ) in this report? Yes r No <br /> d . Does your Board of Directors control this Foundation ? <br /> r Yes No <br /> MINIMUM AND ESSENTIAL BENEFITS <br /> A. RETIREMENT PROGRAM <br /> 1 . What type of retirement plan does your Defined Contribution Plan - B &GCA Plan <br /> organization provide ? -- <br /> Check only one plan . t' Defined Contribution Plan - Not B &GCA <br /> Plan <br /> Defined Benefit Plan <br /> Other (403b , IRA ) <br /> 2a . What is the % of salary contribution ? 10 % <br /> 2b . Of this % , what % does your Organization <br /> contribute ? 100 % <br /> 3 . What is the name of the Plan ? Plan Name : B&GCA Pension Plan <br /> Be BASIC HEALTH & SURGICAL COVERAGE - EMPLOYEE COVERAGE <br /> 1 . What type of Major Medical Insurance does your r HMO <br /> organization provide ? Check all that apply . _ PPO <br /> fi Indemnity <br /> 2 . What % of the Major Medical insurance premium <br /> is paid by your Organization for employee 100 % <br /> coverage ? <br /> 3 . What % of the Major Medical insurance premium <br /> is paid by your Organization for dependent 0 % <br /> coverage ? <br /> 4 . What is the name of the Insurance Carrier( s ) ? r Boys & Girls Clubs Workers ' Association <br /> ( B &GCWA ) ( Provider names that fail under <br /> B&GCWA include : Beech Street, Concentra , CTI , <br /> Health Payors Organization , Multiplan , Preferred <br /> Health Network ( PHN ) , Preferred Plan , QualCare, <br /> WPPN . ) <br /> - Aetna <br /> r Blue Cross &/or Blue Shield <br /> I— Chesterfield Resources <br /> r Kaiser <br /> � Other : ( specify ) <br /> C . GROUP LIFE INSURANCE <br /> 1 . What % of the Group Life insurance premium is <br /> paid by your Organization ? 100 % of Group Life insurance premium <br /> http ://ars . baca. net/OrganizationWizard/AnnualReport/FullReport . asp ?ASID=43105 &- RptY . . . 2/ 14/2003 �4 <br />