401k Plan data: LONGHORN VILLAGE HEALTH & WELFARE BENEFIT PLAN plan

LONGHORN VILLAGE HEALTH & WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	LONGHORN VILLAGE HEALTH & WELFARE BENEFIT PLAN
Plan identification number	505

LONGHORN VILLAGE HEALTH & WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

LONGHORN VILLAGE has sponsored the creation of one or more 401k plans.

Company Name: LONGHORN VILLAGE

Employer identification number (EIN): 200709981

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

Additional information about LONGHORN VILLAGE

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2002-11-26

Company Identification Number: 0800146801

Legal Registered Office Address: 12501 LONGHORN PKWY

AUSTIN
United States of America (USA)
78732

More information about LONGHORN VILLAGE

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LONGHORN VILLAGE HEALTH & WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2022-05-01

Plan Statistics for LONGHORN VILLAGE HEALTH & WELFARE BENEFIT PLAN

401k plan membership statisitcs for LONGHORN VILLAGE HEALTH & WELFARE BENEFIT PLAN

Measure Date Value
2022: LONGHORN VILLAGE HEALTH & WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-05-01 157
Total number of active participants reported on line 7a of the Form 5500 2022-05-01 145
Number of retired or separated participants receiving benefits 2022-05-01 0
Number of other retired or separated participants entitled to future benefits 2022-05-01 0
Total of all active and inactive participants 2022-05-01 145

Measure	Date	Value
2022: LONGHORN VILLAGE HEALTH & WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-05-01	157
Total number of active participants reported on line 7a of the Form 5500	2022-05-01	145
Number of retired or separated participants receiving benefits	2022-05-01	0
Number of other retired or separated participants entitled to future benefits	2022-05-01	0
Total of all active and inactive participants	2022-05-01	145

Form 5500 Responses for LONGHORN VILLAGE HEALTH & WELFARE BENEFIT PLAN

2022: LONGHORN VILLAGE HEALTH & WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-05-01	Type of plan entity	Single employer plan
2022-05-01	First time form 5500 has been submitted	Yes
2022-05-01	Submission has been amended	No
2022-05-01	This submission is the final filing	No
2022-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-05-01	Plan is a collectively bargained plan	No
2022-05-01	Plan funding arrangement – Insurance	Yes
2022-05-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0257733

Policy instance

Insurance contract or identification number	R0257733
Number of Individuals Covered	1
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $4
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY
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 $124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

136628

Policy instance

Insurance contract or identification number	136628
Number of Individuals Covered	37
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $2,123
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOL LIFE, VOL AD&D
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 $10,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,123
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

136627

Policy instance

Insurance contract or identification number	136627
Number of Individuals Covered	145
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $6,840
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
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 $34,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,840
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05754367

Policy instance

Insurance contract or identification number	TM05754367
Number of Individuals Covered	107
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $4,198
Total amount of fees paid to insurance company	USD $468
Are there contracts with allocated funds for individual policies?	0
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	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
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 $45,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,198
Amount paid for insurance broker fees	468
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

267529

Policy instance

Insurance contract or identification number	267529
Number of Individuals Covered	80
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $37,312
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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	Yes
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	No
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 $626,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,312
Insurance broker organization code?	3

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Company Name:	LONGHORN VILLAGE
Employer identification number (EIN):	200709981
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2002-11-26
Company Identification Number:	0800146801
Legal Registered Office Address:	12501 LONGHORN PKWY AUSTIN United States of America (USA) 78732