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| Plan Name | FIRST SOURCE WELFARE BENEFIT PLAN (REVERE) |
| Plan identification number | 524 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | PROVIDER SERVICES |
| Employer identification number (EIN): | 810681796 |
| NAIC Classification: | 623000 |
| NAIC Description: | Nursing and Residential Care Facilities |
Additional information about PROVIDER SERVICES
| Jurisdiction of Incorporation: | Ohio Secretary of State Business Services Division |
| Incorporation Date: | 2005-11-16 |
| Company Identification Number: | 1581849 |
| Legal Registered Office Address: |
2500 COUNTRY CLUB BLVD SUITE 255 NORTH OLMSTED United States of America (USA) 44070 |
More information about PROVIDER SERVICES
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 524 | 2017-01-01 | JOHN KRYSTOWSKI |
| Measure | Date | Value |
|---|---|---|
| 2017: FIRST SOURCE WELFARE BENEFIT PLAN (REVERE) 2017 401k membership | ||
| Total participants, beginning-of-year | 2017-01-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 1,166 |
| Total of all active and inactive participants | 2017-01-01 | 1,166 |
| Total participants | 2017-01-01 | 1,166 |
| 2017: FIRST SOURCE WELFARE BENEFIT PLAN (REVERE) 2017 form 5500 responses | ||
|---|---|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | First time form 5500 has been submitted | Yes |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) | |
| Policy contract number | 000403005034 |
| Policy instance | 1 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) | |
| Policy contract number | 0160695 |
| Policy instance | 2 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) | |
| Policy contract number | 701308 |
| Policy instance | 3 |
| FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 ) | |
| Policy contract number | 9830100/9830118 |
| Policy instance | 4 |
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) | |
| Policy contract number | 246530 |
| Policy instance | 5 |
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) | |
| Policy contract number | 695971 |
| Policy instance | 6 |
| ENVISION PHARMACEUTICAL SERVICES, LLC (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | FIRSTSOURC |
| Policy instance | 7 |
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