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| Plan Name | COURTLAND II HEALTH AND WELFARE PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | COURTLAND II |
| Employer identification number (EIN): | 232763601 |
| 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 |
|---|---|---|---|---|---|
| 501 | 2009-06-01 | DONALD R LEVESQUE | |||
| 501 | 2009-06-01 | MICHAEL DEMARCO | 2019-10-02 |
| Measure | Date | Value |
|---|---|---|
| 2009: COURTLAND II HEALTH AND WELFARE PLAN 2009 401k membership | ||
| Total participants, beginning-of-year | 2009-06-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-06-01 | 68 |
| Total of all active and inactive participants | 2009-06-01 | 68 |
| Number of retired or separated participants receiving benefits | 2009-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-06-01 | 0 |
| Number of employers contributing to the scheme | 2009-06-01 | 0 |
| 2009: COURTLAND II HEALTH AND WELFARE PLAN 2009 form 5500 responses | ||
|---|---|---|
| 2009-06-01 | Type of plan entity | Single employer plan |
| 2009-06-01 | First time form 5500 has been submitted | Yes |
| 2009-06-01 | Submission has been amended | Yes |
| 2009-06-01 | This submission is the final filing | No |
| 2009-06-01 | Plan funding arrangement – Insurance | Yes |
| 2009-06-01 | Plan benefit arrangement – Insurance | Yes |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) | |
| Policy contract number | H12898-2 |
| Policy instance | 1 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) | |
| Policy contract number | 124551 |
| Policy instance | 2 |
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) | |
| Policy contract number | 377413 |
| Policy instance | 3 |
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) | |
| Policy contract number | 2803 |
| Policy instance | 4 |
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