401k Plan data: SALEM SENIOR HOUSING, INC. plan

SALEM SENIOR HOUSING, INC. 401k Plan overview

Plan Name	SALEM SENIOR HOUSING, INC.
Plan identification number	503

SALEM SENIOR HOUSING, INC. Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Long-term disability cover

401k Sponsoring company profile

SALEM SENIOR HOUSING, INC. has sponsored the creation of one or more 401k plans.

Company Name: SALEM SENIOR HOUSING, INC.

Employer identification number (EIN): 010599602

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SALEM SENIOR HOUSING, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2015-06-01 KRISTI SNIPES GLENN CLARK 2016-10-21
503 2011-06-01 KRISTI SNIPES GLENN CLARK 2012-10-12

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
503	2015-06-01	KRISTI SNIPES		GLENN CLARK	2016-10-21
503	2011-06-01	KRISTI SNIPES		GLENN CLARK	2012-10-12

Plan Statistics for SALEM SENIOR HOUSING, INC.

401k plan membership statisitcs for SALEM SENIOR HOUSING, INC.

Measure Date Value
2015: SALEM SENIOR HOUSING, INC. 2015 401k membership
Total participants, beginning-of-year 2015-06-01 165
Total number of active participants reported on line 7a of the Form 5500 2015-06-01 0
Total of all active and inactive participants 2015-06-01 0
Total participants 2015-06-01 0
2011: SALEM SENIOR HOUSING, INC. 2011 401k membership
Total participants, beginning-of-year 2011-06-01 219
Total number of active participants reported on line 7a of the Form 5500 2011-06-01 213
Total of all active and inactive participants 2011-06-01 213
Total participants 2011-06-01 213

Measure	Date	Value
2015: SALEM SENIOR HOUSING, INC. 2015 401k membership
Total participants, beginning-of-year	2015-06-01	165
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	0
Total of all active and inactive participants	2015-06-01	0
Total participants	2015-06-01	0
2011: SALEM SENIOR HOUSING, INC. 2011 401k membership
Total participants, beginning-of-year	2011-06-01	219
Total number of active participants reported on line 7a of the Form 5500	2011-06-01	213
Total of all active and inactive participants	2011-06-01	213
Total participants	2011-06-01	213

Form 5500 Responses for SALEM SENIOR HOUSING, INC.

2015: SALEM SENIOR HOUSING, INC. 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	First time form 5500 has been submitted	Yes
2015-06-01	Submission has been amended	No
2015-06-01	This submission is the final filing	Yes
2015-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-06-01	Plan is a collectively bargained plan	No
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes
2011: SALEM SENIOR HOUSING, INC. 2011 form 5500 responses
2011-06-01	Type of plan entity	Single employer plan
2011-06-01	First time form 5500 has been submitted	Yes
2011-06-01	Submission has been amended	No
2011-06-01	This submission is the final filing	No
2011-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-06-01	Plan is a collectively bargained plan	No
2011-06-01	Plan funding arrangement – Insurance	Yes
2011-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 122209

Policy instance

Insurance contract or identification number	LTD 122209
Number of Individuals Covered	0
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $2,476
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,476
Insurance broker organization code?	3
Insurance broker name	JBA BENEFITS OF THE CAROLINAS LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 122209

Policy instance

Insurance contract or identification number	LTD 122209
Number of Individuals Covered	213
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $6,360
Total amount of fees paid to insurance company	USD $1,008
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010016411

Policy instance

Insurance contract or identification number	000010016411
Number of Individuals Covered	237
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $6,671
Total amount of fees paid to insurance company	USD $6,671
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SALEM SENIOR HOUSING, INC.
Employer identification number (EIN):	010599602
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities