401k Plan data: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER plan

ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 401k Plan overview

Plan Name	ST. JOHNSVILLE REHABILITATION AND NURSING CENTER
Plan identification number	502

ST. JOHNSVILLE REHABILITATION AND NURSING CENTER Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

ST JOHNSVILLE A has sponsored the creation of one or more 401k plans.

Company Name: ST JOHNSVILLE A

Employer identification number (EIN): 201388111

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ST. JOHNSVILLE REHABILITATION AND NURSING CENTER

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2012-01-01 MICHELE DYGERT MICHELE DYGERT 2014-01-31
502 2011-01-01 LISA VOLK 2012-06-15 LISA VOLK 2012-06-15

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2012-01-01	MICHELE DYGERT		MICHELE DYGERT	2014-01-31
502	2011-01-01	LISA VOLK	2012-06-15	LISA VOLK	2012-06-15

Plan Statistics for ST. JOHNSVILLE REHABILITATION AND NURSING CENTER

401k plan membership statisitcs for ST. JOHNSVILLE REHABILITATION AND NURSING CENTER

Measure Date Value
2012: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 2012 401k membership
Total participants, beginning-of-year 2012-01-01 81
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 71
Total of all active and inactive participants 2012-01-01 71

Measure	Date	Value
2012: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 2012 401k membership
Total participants, beginning-of-year	2012-01-01	81
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	71
Total of all active and inactive participants	2012-01-01	71

Form 5500 Responses for ST. JOHNSVILLE REHABILITATION AND NURSING CENTER

2012: ST. JOHNSVILLE REHABILITATION AND NURSING CENTER 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00122381

Policy instance

Insurance contract or identification number	00122381
Number of Individuals Covered	71
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $32,717
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $575,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,717
Insurance broker organization code?	3
Insurance broker name	BENEFIT CONSULTING GROUP, INC.

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Company Name:	ST JOHNSVILLE A
Employer identification number (EIN):	201388111
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities