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SAINT JOHN XXIII HOME VISION PLAN 401k Plan overview

Plan NameSAINT JOHN XXIII HOME VISION PLAN
Plan identification number 505

SAINT JOHN XXIII HOME VISION PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • 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

SAINT JOHN XXIII HOME has sponsored the creation of one or more 401k plans.

Company Name:SAINT JOHN XXIII HOME
Employer identification number (EIN):251214797
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SAINT JOHN XXIII HOME VISION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5052019-01-01KIRK HAWTHORNE2020-07-27
5052018-01-01
5052017-01-01
5052016-01-01
5052015-01-01KIRK HAWTHORNE
5052014-01-013977
5052013-01-01KIRK HAWTHORNE
5052012-01-01KIRK HAWTHORNE
5052011-01-01KIRK HAWTHORNE
5052009-01-01KIRK HAWTHORNE

Plan Statistics for SAINT JOHN XXIII HOME VISION PLAN

401k plan membership statisitcs for SAINT JOHN XXIII HOME VISION PLAN

Measure Date Value
2019: SAINT JOHN XXIII HOME VISION PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-0186
Total number of active participants reported on line 7a of the Form 55002019-01-0183
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-0183
2018: SAINT JOHN XXIII HOME VISION PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-0193
Total number of active participants reported on line 7a of the Form 55002018-01-0186
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-0186
2017: SAINT JOHN XXIII HOME VISION PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-0195
Total number of active participants reported on line 7a of the Form 55002017-01-0193
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-0193
2016: SAINT JOHN XXIII HOME VISION PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01102
Total number of active participants reported on line 7a of the Form 55002016-01-0195
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-0195
2015: SAINT JOHN XXIII HOME VISION PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01105
Total number of active participants reported on line 7a of the Form 55002015-01-01102
Total of all active and inactive participants2015-01-01102
2014: SAINT JOHN XXIII HOME VISION PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-0198
Total number of active participants reported on line 7a of the Form 55002014-01-01105
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01105
2013: SAINT JOHN XXIII HOME VISION PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01104
Total number of active participants reported on line 7a of the Form 55002013-01-0198
Total of all active and inactive participants2013-01-0198
2012: SAINT JOHN XXIII HOME VISION PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-0194
Total number of active participants reported on line 7a of the Form 55002012-01-01104
Total of all active and inactive participants2012-01-01104
2011: SAINT JOHN XXIII HOME VISION PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-0198
Total number of active participants reported on line 7a of the Form 55002011-01-0194
Total of all active and inactive participants2011-01-0194
2009: SAINT JOHN XXIII HOME VISION PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01108
Total number of active participants reported on line 7a of the Form 55002009-01-01104
Total of all active and inactive participants2009-01-01104

Form 5500 Responses for SAINT JOHN XXIII HOME VISION PLAN

2019: SAINT JOHN XXIII HOME VISION PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: SAINT JOHN XXIII HOME VISION PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: SAINT JOHN XXIII HOME VISION PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: SAINT JOHN XXIII HOME VISION PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: SAINT JOHN XXIII HOME VISION PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: SAINT JOHN XXIII HOME VISION PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: SAINT JOHN XXIII HOME VISION PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: SAINT JOHN XXIII HOME VISION PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: SAINT JOHN XXIII HOME VISION PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2009: SAINT JOHN XXIII HOME VISION PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01This submission is the final filingNo
2009-01-01Plan funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number04161742
Policy instance 1
Insurance contract or identification number04161742
Number of Individuals Covered83
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $114
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $5,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $114
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number04161742
Policy instance 1
Insurance contract or identification number04161742
Number of Individuals Covered86
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $124
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $6,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $124
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number04161742
Policy instance 1
Insurance contract or identification number04161742
Number of Individuals Covered93
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $137
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $6,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $137
Insurance broker organization code?3
Insurance broker nameGILBERTS INSURANCE AGENCY

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