401k Plan data: SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC plan

SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC 401k Plan overview

Plan Name	SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC
Plan identification number	504

SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC has sponsored the creation of one or more 401k plans.

Company Name: SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC

Employer identification number (EIN): 261942031

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
504 2022-01-01 KENNETH J. MCCARTHY 2023-09-22

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
504	2022-01-01	KENNETH J. MCCARTHY	2023-09-22

Plan Statistics for SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC

401k plan membership statisitcs for SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC

Measure Date Value
2022: SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC 2022 401k membership
Total participants, beginning-of-year 2022-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 295
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 295
Number of employers contributing to the scheme 2022-01-01 0

Measure	Date	Value
2022: SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC 2022 401k membership
Total participants, beginning-of-year	2022-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	295
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	295
Number of employers contributing to the scheme	2022-01-01	0

Form 5500 Responses for SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC

2022: SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	First time form 5500 has been submitted	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

300797

Policy instance

Insurance contract or identification number	300797
Number of Individuals Covered	208
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $51,830
Total amount of fees paid to insurance company	USD $868
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,727,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,830
Amount paid for insurance broker fees	868
Additional information about fees paid to insurance broker	BROKER INCENTIVE PROGRAM
Insurance broker organization code?	3

DELTA DENTAL OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55034 )

Policy contract number

670352

Policy instance

Insurance contract or identification number	670352
Number of Individuals Covered	279
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $12,588
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,588
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HEALTHPARTNERS INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 44547 )

Policy contract number

27945

Policy instance

Insurance contract or identification number	27945
Number of Individuals Covered	47
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $9,763
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $294,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	9763
Additional information about fees paid to insurance broker	BROKER SERVICE FEE, INDIRECT COMPENSATION
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

936027

Policy instance

Insurance contract or identification number	936027
Number of Individuals Covered	6
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $457
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $457
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

168169

Policy instance

Insurance contract or identification number	168169
Number of Individuals Covered	295
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,319
Total amount of fees paid to insurance company	USD $0
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	ACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,319
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	SOUTHVIEW SENIOR LIVING MANAGEMENT, LLC
Employer identification number (EIN):	261942031
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities