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| Plan Name | MEDICAL |
| Plan identification number | 505 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | DOMINION SENIOR LIVING SERVICES |
| Employer identification number (EIN): | 201457828 |
| 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 |
|---|---|---|---|---|---|
| 505 | 2022-10-01 | ALLISON RAMIREZ | 2023-12-13 | ||
| 505 | 2021-10-01 | ALLISON RAMIREZ | 2023-04-18 |
| Measure | Date | Value |
|---|---|---|
| 2022: MEDICAL 2022 401k membership | ||
| Total participants, beginning-of-year | 2022-10-01 | 625 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-10-01 | 617 |
| Number of retired or separated participants receiving benefits | 2022-10-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2022-10-01 | 0 |
| Total of all active and inactive participants | 2022-10-01 | 622 |
| Number of employers contributing to the scheme | 2022-10-01 | 0 |
| 2021: MEDICAL 2021 401k membership | ||
| Total participants, beginning-of-year | 2021-10-01 | 625 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 620 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 620 |
| Number of employers contributing to the scheme | 2021-10-01 | 0 |
| 2022: MEDICAL 2022 form 5500 responses | ||
|---|---|---|
| 2022-10-01 | Type of plan entity | Single employer plan |
| 2022-10-01 | Plan funding arrangement – Insurance | Yes |
| 2022-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: MEDICAL 2021 form 5500 responses | ||
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | First time form 5500 has been submitted | Yes |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) | |||||||||||||||||
| Policy contract number | 90807 | ||||||||||||||||
| Policy instance | 1 | ||||||||||||||||
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| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) | |||||||||||||||||
| Policy contract number | 90807 | ||||||||||||||||
| Policy instance | 1 | ||||||||||||||||
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