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| Plan Name | 12 OAKS MANAGEMENT SERVICES INC. |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | 12 OAKS MANAGEMENT SERVICES INC. |
| Employer identification number (EIN): | 752418094 |
| NAIC Classification: | 623000 |
| NAIC Description: | Nursing and Residential Care Facilities |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2019-05-01 | MISTY ROUNTREE | 2020-09-14 | ||
| 501 | 2018-05-01 | MISTY ROUNTREE | 2019-11-12 | ||
| 501 | 2017-05-01 | PAIGE BUBLIK | PAIGE BUBLIK | 2019-02-15 |
| 2019: 12 OAKS MANAGEMENT SERVICES INC. 2019 form 5500 responses | ||
|---|---|---|
| 2019-05-01 | Type of plan entity | Single employer plan |
| 2019-05-01 | Plan funding arrangement – Insurance | Yes |
| 2019-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: 12 OAKS MANAGEMENT SERVICES INC. 2018 form 5500 responses | ||
| 2018-05-01 | Type of plan entity | Single employer plan |
| 2018-05-01 | Plan funding arrangement – Insurance | Yes |
| 2018-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: 12 OAKS MANAGEMENT SERVICES INC. 2017 form 5500 responses | ||
| 2017-05-01 | Type of plan entity | Single employer plan |
| 2017-05-01 | Submission has been amended | No |
| 2017-05-01 | This submission is the final filing | No |
| 2017-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-05-01 | Plan is a collectively bargained plan | No |
| 2017-05-01 | Plan funding arrangement – Insurance | Yes |
| 2017-05-01 | Plan benefit arrangement – Insurance | Yes |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) | |
| Policy contract number | 611095 |
| Policy instance | 1 |
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) | |
| Policy contract number | 34855 |
| Policy instance | 2 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | CI960239 |
| Policy instance | 3 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) | |
| Policy contract number | 611095 |
| Policy instance | 1 |
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) | |
| Policy contract number | 34855 |
| Policy instance | 2 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | FLX967346 |
| Policy instance | 3 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | FLX967346 |
| Policy instance | 1 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) | |
| Policy contract number | 00611095 |
| Policy instance | 2 |
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) | |
| Policy contract number | 34855 |
| Policy instance | 3 |
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