401k Plan data: RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN plan

RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN
Plan identification number	501

RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Other welfare benefit cover

401k Sponsoring company profile

RIVERSIDE FOUNDATION has sponsored the creation of one or more 401k plans.

Company Name: RIVERSIDE FOUNDATION

Employer identification number (EIN): 362880335

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-01-01 DEBORAH ROGERS
501 2014-01-01 DEBORAH ROGERS
501 2013-01-01 DEBORAH ROGERS

Plan id#	Filing Submission Date	Name of Administrator
501	2015-01-01	DEBORAH ROGERS
501	2014-01-01	DEBORAH ROGERS
501	2013-01-01	DEBORAH ROGERS

Plan Statistics for RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN

401k plan membership statisitcs for RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN

Measure Date Value
2015: RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 112
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 117
Total of all active and inactive participants 2015-01-01 117
Total participants 2015-01-01 0
2014: RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 111
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 112
Total of all active and inactive participants 2014-01-01 112
Total participants 2014-01-01 0
2013: RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 108
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 111
Total of all active and inactive participants 2013-01-01 111
Total participants 2013-01-01 0

Measure	Date	Value
2015: RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	112
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	117
Total of all active and inactive participants	2015-01-01	117
Total participants	2015-01-01	0
2014: RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	111
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	112
Total of all active and inactive participants	2014-01-01	112
Total participants	2014-01-01	0
2013: RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	108
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	111
Total of all active and inactive participants	2013-01-01	111
Total participants	2013-01-01	0

Form 5500 Responses for RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN

2015: RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: RIVERSIDE FOUNDATION WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	First time form 5500 has been submitted	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

LAND OF LINCOLN HEALTH (National Association of Insurance Commissioners NAIC id number: 15102 )

Policy contract number

LL90012001

Policy instance

Insurance contract or identification number	LL90012001
Number of Individuals Covered	35
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $13,576
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $294,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,576
Insurance broker organization code?	3
Insurance broker name	MID AMERICAN GROUP

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5470143

Policy instance

Insurance contract or identification number	5470143
Number of Individuals Covered	37
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,161
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,161
Insurance broker organization code?	3
Insurance broker name	MID AMERICAN GROUP INC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

701323

Policy instance

Insurance contract or identification number	701323
Number of Individuals Covered	43
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $436
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $436
Insurance broker organization code?	3
Insurance broker name	MID AMERICAN GROUP

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

09694

Policy instance

Insurance contract or identification number	09694
Number of Individuals Covered	117
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $998
Total amount of fees paid to insurance company	USD $41
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $998
Insurance broker organization code?	3
Amount paid for insurance broker fees	41
Additional information about fees paid to insurance broker	FEES
Insurance broker name	AXA ASSISTANCE, USA

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5470143

Policy instance

Insurance contract or identification number	5470143
Number of Individuals Covered	37
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,953
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,953
Insurance broker organization code?	3
Insurance broker name	MID AMERICAN GROUP INC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

701323

Policy instance

Insurance contract or identification number	701323
Number of Individuals Covered	36
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $310
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $310
Insurance broker organization code?	3
Insurance broker name	MID AMERICAN GROUP

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

825855

Policy instance

Insurance contract or identification number	825855
Number of Individuals Covered	27
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,858
Total amount of fees paid to insurance company	USD $500
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $279,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,858
Amount paid for insurance broker fees	500
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	MID AMERICAN GROUP

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

09694

Policy instance

Insurance contract or identification number	09694
Number of Individuals Covered	112
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $822
Total amount of fees paid to insurance company	USD $39
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $822
Insurance broker organization code?	3
Amount paid for insurance broker fees	39
Additional information about fees paid to insurance broker	FEES
Insurance broker name	AXA ASSISTANCE, USA

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

679109/701323

Policy instance

Insurance contract or identification number	679109/701323
Number of Individuals Covered	32
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,856
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,856
Insurance broker organization code?	3
Insurance broker name	MID AMERICAN GROUP

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B25855/P32770

Policy instance

Insurance contract or identification number	B25855/P32770
Number of Individuals Covered	22
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,692
Total amount of fees paid to insurance company	USD $293
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $191,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,692
Amount paid for insurance broker fees	293
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	MID AMERICAN GROUP

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

09694

Policy instance

Insurance contract or identification number	09694
Number of Individuals Covered	111
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $678
Total amount of fees paid to insurance company	USD $99
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $678
Amount paid for insurance broker fees	58
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	AXA ASSISTANCE, USA

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Company Name:	RIVERSIDE FOUNDATION
Employer identification number (EIN):	362880335
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities