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ObjectId: 202013179349308126 - Submission: 2020-11-12
TIN: 43-1684044
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
Attach to Form 990.
Go to
www.irs.gov/Form990
for instructions and the latest information.
OMB No. 1545-0047
20
19
Open to Public Inspection
Name of the organization
COX HEALTH SYSTEMS INSURANCE COMPANY
Employer identification number
43-1684044
Part I
Identification of Disregarded Entities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 33.
(a)
Name, address, and EIN (if applicable) of disregarded entity
(b)
Primary activity
(c)
Legal domicile (state
or foreign country)
(d)
Total income
(e)
End-of-year assets
(f)
Direct controlling
entity
Part II
Identification of Related Tax-Exempt Organizations.
Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.
(a)
Name, address, and EIN of related organization
(b)
Primary activity
(c)
Legal domicile (state
or foreign country)
(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))
(f)
Direct controlling
entity
(g)
Section 512(b)(13) controlled entity?
Yes
No
(1)
COX HEALTH SYSTEMS HMO INC
PO BOX 5750
SPRINGFIELD
,
MO
65801
43-1757075
INSURANCE
MO
501(C)(4)
COXHEALTH
No
(2)
LESTER E COX MEDICAL CENTERS
1423 N JEFFERSON
SPRINGFIELD
,
MO
65802
44-0577118
HOSPITAL
MO
501(C)(3)
3
COXHEALTH
No
(3)
COX ALTERNATIVE CARE OF THE OZARKS INC
PO BOX 10939
SPRINGFIELD
,
MO
65808
43-1641925
HOME HEALTH
MO
501(C)(3)
10
LESTER E COX
No
(4)
COXHEALTH FOUNDATION
3525 S NATIONAL SUITE 204
SPRINGFIELD
,
MO
65807
43-6810485
FUNDRAISING
MO
501(C)(3)
12 A I
LESTER E COX
No
(5)
COXHEALTH HME CRE SVCS OF THE MDWST INC
3850 S NATIONAL
SPRINGFIELD
,
MO
65807
26-4781194
HOME HEALTH
MO
501(C)(3)
10
LESTER E COX
No
(6)
COX HPS OF THE OZARKS INC
2220 W SUNSET
SPRINGFIELD
,
MO
65807
43-1641927
HOME HEALTH
MO
501(C)(3)
10
LESTER E COX
No
(7)
COX-MONETT HOSPITAL INC
801 N LINCOLN AVE
MONETT
,
MO
65708
43-1656689
HOSPITAL
MO
501(C)(3)
3
LESTER E COX
No
(8)
HEALTH ENRICHMENT SERVICES INC
3801 S NATIONAL
SPRINGFIELD
,
MO
65807
36-3263313
MED SERVICES
MO
501(C)(3)
7
LESTER E COX
No
(9)
HEALTHCARE SERVICES OF THE OZARKS INC
PO BOX 10939
SPRINGFIELD
,
MO
65808
43-1641928
HOME HEALTH
MO
501(C)(3)
10
LESTER E COX
No
(10)
PRIMROSE PLACE INC
1115 E PRIMROSE
SPRINGFIELD
,
MO
65807
43-1183783
SUPPORT
MO
501(C)(3)
12 A I
LESTER E COX
No
(11)
COX MEDICAL CTR GENPROF LIAB LOSS FUND
1423 N JEFFERSON
SPRINGFIELD
,
MO
65802
36-6668576
SELF-INSURANC
MO
501(C)(3)
12 A I
LESTER E COX
No
(12)
SKAGGS COMM HOSP ASSOC (COX MC BRANSON)
525 BRANSON LANDING BOULEVARD
BRANSON
,
MO
65616
44-0584290
HOSPITAL
MO
501(C)(3)
3
LESTER E COX
No
(13)
COX COLLEGE
1423 NORTH JEFFERSON
SPRINGFIELD
,
MO
65802
47-5148345
EDUCATION
MO
501(C)(3)
2
LESTER E COX
No
(14)
COXHEALTH
1423 N JEFFERSON
SPRINGFIELD
,
MO
65802
47-1087427
HOLDING CO
MO
501(C)(3)
12 B II
NA
No
(15)
COX MEDICAL GROUP
1423 N JEFFERSON
SPRINGFIELD
,
MO
65802
47-1087566
PHYSICIANS
MO
501(C)(3)
10
COXHEALTH
No
(16)
COX MEDICAL GROUP CLINICS
3801 S NATIONAL
SPRINGFIELD
,
MO
65807
37-1830627
HEALTHCARE
MO
501(C)(3)
10
COXHEALTH
No
(17)
COX BARTON COUNTY HOSPITAL
1423 N JEFFERSON
SPRINGFIELD
,
MO
65802
82-3300758
HOSPITAL
MO
501(C)(3)
3
COXHEALTH
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2019
Page 2
Schedule R (Form 990) 2019
Page
2
Part III
Identification of Related Organizations Taxable as a Partnership.
Complete if the organization answered "Yes" on Form 990, Part IV, line 34, because it had one or more related organizations treated as a partnership during the tax year.
(a)
Name, address, and EIN of
related organization
(b)
Primary activity
(c)
Legal
domicile
(state or foreign
country)
(d)
Direct controlling
entity
(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)
(f)
Share of total income
(g)
Share of end-of-year
assets
(h)
Disproprtionate allocations?
(i)
Code V-UBI
amount in box 20 of
Schedule K-1
(Form 1065)
(j)
General or
managing
partner?
(k)
Percentage
ownership
Yes
No
Yes
No
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust.
Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.
(a)
Name, address, and EIN of
related organization
(b)
Primary activity
(c)
Legal
domicile
(state or foreign
country)
(d)
Direct controlling
entity
(e)
Type of entity
(C corp, S corp,
or trust)
(f)
Share of total income
(g)
Share of end-of-year
assets
(h)
Percentage
ownership
(i)
Section 512(b)(13) controlled entity?
Yes
No
(1)
MEDICAL DEVELOPMENTS
1423 N JEFFERSON AVE
SPRINGFIELD
,
MO
65802
43-1622182
PHARMACY
MO
LESTER E COX
C CORP
No
(2)
INSURANCE COMPANY OF SPRINGFIELD INC
GRAND PAVILLION CORPORATE CENTRE
GRAND CAYMAN
KY1-11
CJ
CAPTIVE INSURANCE
CJ
LESTER E COX
C CORP
No
(3)
COX TAXABLE CLOSE CORPORATION
1423 N JEFFERSON AVE
SPRINGFIELD
,
MO
65802
47-2573263
MEDICAL CLINIC
MO
COX MED GROUP
C CORP
No
(4)
FERRELL-DUNCAN CLINIC INC
1001 E PRIMROSE
SPRINGFIELD
,
MO
65808
43-0991578
PHYSICIANS
MO
CTCC
C CORP
No
Schedule R (Form 990) 2019
Page 3
Schedule R (Form 990) 2019
Page
3
Part V
Transactions With Related Organizations.
Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note.
Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1
During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a
Receipt of
(i)
interest,
(ii)
annuities,
(iii)
royalties, or
(iv)
rent from a controlled entity
.....................
1a
No
b
Gift, grant, or capital contribution to related organization(s)
............................
1b
No
c
Gift, grant, or capital contribution from related organization(s)
............................
1c
Yes
d
Loans or loan guarantees to or for related organization(s)
............................
1d
Yes
e
Loans or loan guarantees by related organization(s)
............................
1e
Yes
f
Dividends from related organization(s)
............................
1f
No
g
Sale of assets to related organization(s)
............................
1g
No
h
Purchase of assets from related organization(s)
............................
1h
No
i
Exchange of assets with related organization(s)
............................
1i
No
j
Lease of facilities, equipment, or other assets to related organization(s)
.......................
1j
No
k
Lease of facilities, equipment, or other assets from related organization(s)
......................
1k
No
l
Performance of services or membership or fundraising solicitations for related organization(s)
.....................
1l
No
m
Performance of services or membership or fundraising solicitations by related organization(s)
.................
1m
Yes
n
Sharing of facilities, equipment, mailing lists, or other assets with related organization(s)
...................
1n
Yes
o
Sharing of paid employees with related organization(s)
............................
1o
Yes
p
Reimbursement paid to related organization(s) for expenses
............................
1p
Yes
q
Reimbursement paid by related organization(s) for expenses
............................
1q
No
r
Other transfer of cash or property to related organization(s)
............................
1r
No
s
Other transfer of cash or property from related organization(s)
............................
1s
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of related organization
(b)
Transaction
type (a-s)
(c)
Amount involved
(d)
Method of determining amount involved
Schedule R (Form 990) 2019
Page 4
Schedule R (Form 990) 2019
Page
4
Part VI
Unrelated Organizations Taxable as a Partnership.
Complete if the organization answered "Yes" on Form 990, Part IV, line 37.
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity
(b)
Primary activity
(c)
Legal domicile
(state or foreign
country)
(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)
(e)
Are all partners
section
501(c)(3)
organizations?
(f)
Share of total income
(g)
Share of
end-of-year
assets
(h)
Disproprtionate allocations?
(i)
Code V-UBI
amount in box 20
of Schedule K-1
(Form 1065)
(j)
General or
managing
partner?
(k)
Percentage
ownership
Yes
No
Yes
No
Yes
No
Schedule R (Form 990) 2019
Page 5
Schedule R (Form 990) 2019
Page
5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R. (see instructions).
Return Reference
Explanation
Schedule R (Form 990) 2019
Additional Data
Software ID:
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