401k Plan data: BETHANY HOME, INC. WRAP PLAN plan

BETHANY HOME, INC. WRAP PLAN 401k Plan overview

Plan Name	BETHANY HOME, INC. WRAP PLAN
Plan identification number	504

BETHANY HOME, INC. WRAP PLAN Benefits

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

401k Sponsoring company profile

BETHANY HOME, INC. has sponsored the creation of one or more 401k plans.

Company Name: BETHANY HOME, INC.

Employer identification number (EIN): 390868849

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

Additional information about BETHANY HOME, INC.

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1957-09-30

Company Identification Number: 167684

More information about BETHANY HOME, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BETHANY HOME, INC. WRAP PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
504 2022-12-01
504 2020-12-01
504 2018-12-01
504 2017-12-01

Plan Statistics for BETHANY HOME, INC. WRAP PLAN

401k plan membership statisitcs for BETHANY HOME, INC. WRAP PLAN

Measure Date Value
2022: BETHANY HOME, INC. WRAP PLAN 2022 401k membership
Total participants, beginning-of-year 2022-12-01 105
Total number of active participants reported on line 7a of the Form 5500 2022-12-01 103
Number of retired or separated participants receiving benefits 2022-12-01 0
Number of other retired or separated participants entitled to future benefits 2022-12-01 0
Total of all active and inactive participants 2022-12-01 103
2020: BETHANY HOME, INC. WRAP PLAN 2020 401k membership
Total participants, beginning-of-year 2020-12-01 110
Total number of active participants reported on line 7a of the Form 5500 2020-12-01 95
Total of all active and inactive participants 2020-12-01 95
2018: BETHANY HOME, INC. WRAP PLAN 2018 401k membership
Total participants, beginning-of-year 2018-12-01 114
Total number of active participants reported on line 7a of the Form 5500 2018-12-01 96
Number of retired or separated participants receiving benefits 2018-12-01 2
Total of all active and inactive participants 2018-12-01 98
2017: BETHANY HOME, INC. WRAP PLAN 2017 401k membership
Total participants, beginning-of-year 2017-12-01 115
Total number of active participants reported on line 7a of the Form 5500 2017-12-01 95
Total of all active and inactive participants 2017-12-01 95

Measure	Date	Value
2022: BETHANY HOME, INC. WRAP PLAN 2022 401k membership
Total participants, beginning-of-year	2022-12-01	105
Total number of active participants reported on line 7a of the Form 5500	2022-12-01	103
Number of retired or separated participants receiving benefits	2022-12-01	0
Number of other retired or separated participants entitled to future benefits	2022-12-01	0
Total of all active and inactive participants	2022-12-01	103
2020: BETHANY HOME, INC. WRAP PLAN 2020 401k membership
Total participants, beginning-of-year	2020-12-01	110
Total number of active participants reported on line 7a of the Form 5500	2020-12-01	95
Total of all active and inactive participants	2020-12-01	95
2018: BETHANY HOME, INC. WRAP PLAN 2018 401k membership
Total participants, beginning-of-year	2018-12-01	114
Total number of active participants reported on line 7a of the Form 5500	2018-12-01	96
Number of retired or separated participants receiving benefits	2018-12-01	2
Total of all active and inactive participants	2018-12-01	98
2017: BETHANY HOME, INC. WRAP PLAN 2017 401k membership
Total participants, beginning-of-year	2017-12-01	115
Total number of active participants reported on line 7a of the Form 5500	2017-12-01	95
Total of all active and inactive participants	2017-12-01	95

Form 5500 Responses for BETHANY HOME, INC. WRAP PLAN

2022: BETHANY HOME, INC. WRAP PLAN 2022 form 5500 responses
2022-12-01	Type of plan entity	Single employer plan
2022-12-01	Submission has been amended	No
2022-12-01	This submission is the final filing	No
2022-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-12-01	Plan is a collectively bargained plan	No
2022-12-01	Plan funding arrangement – Insurance	Yes
2022-12-01	Plan benefit arrangement – Insurance	Yes
2020: BETHANY HOME, INC. WRAP PLAN 2020 form 5500 responses
2020-12-01	Type of plan entity	Single employer plan
2020-12-01	Submission has been amended	No
2020-12-01	This submission is the final filing	No
2020-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-12-01	Plan is a collectively bargained plan	No
2020-12-01	Plan funding arrangement – Insurance	Yes
2020-12-01	Plan benefit arrangement – Insurance	Yes
2018: BETHANY HOME, INC. WRAP PLAN 2018 form 5500 responses
2018-12-01	Type of plan entity	Single employer plan
2018-12-01	Submission has been amended	No
2018-12-01	This submission is the final filing	No
2018-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-12-01	Plan is a collectively bargained plan	No
2018-12-01	Plan funding arrangement – Insurance	Yes
2018-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-12-01	Plan benefit arrangement – Insurance	Yes
2018-12-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: BETHANY HOME, INC. WRAP PLAN 2017 form 5500 responses
2017-12-01	Type of plan entity	Single employer plan
2017-12-01	Submission has been amended	No
2017-12-01	This submission is the final filing	No
2017-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-12-01	Plan is a collectively bargained plan	No
2017-12-01	Plan funding arrangement – Insurance	Yes
2017-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-12-01	Plan benefit arrangement – Insurance	Yes
2017-12-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

8168

Policy instance

Insurance contract or identification number	8168
Number of Individuals Covered	58
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $235
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $4,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $235
Insurance broker organization code?	3

SECURITY HEALTH PLAN OF WISCONSIN, INC. (National Association of Insurance Commissioners NAIC id number: 96881 )

Policy contract number

C0004615825

Policy instance

Insurance contract or identification number	C0004615825
Number of Individuals Covered	83
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $19,146
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,146
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400150198

Policy instance

Insurance contract or identification number	400150198
Number of Individuals Covered	13
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $627
Total amount of fees paid to insurance company	USD $61
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE; VOLUNTARY AD&D
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 Carrier	USD $4,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $627
Insurance broker organization code?	3
Amount paid for insurance broker fees	61
Additional information about fees paid to insurance broker	OVERRIDES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150196

Policy instance

Insurance contract or identification number	10150196
Number of Individuals Covered	11
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $721
Total amount of fees paid to insurance company	USD $66
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $4,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $721
Insurance broker organization code?	3
Amount paid for insurance broker fees	66
Additional information about fees paid to insurance broker	OVERRIDES

COMBINED INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

BKRC17577

Policy instance

Insurance contract or identification number	BKRC17577
Number of Individuals Covered	30
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $456
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT; CRITICAL ILLNESS
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 Carrier	USD $5,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $452
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150195

Policy instance

Insurance contract or identification number	10150195
Number of Individuals Covered	97
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $491
Total amount of fees paid to insurance company	USD $45
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
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 Carrier	USD $3,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $491
Insurance broker organization code?	3
Amount paid for insurance broker fees	45
Additional information about fees paid to insurance broker	OVERRIDES

SECURITY HEALTH PLAN OF WISCONSIN, INC. (National Association of Insurance Commissioners NAIC id number: 96881 )

Policy contract number

C0004508479

Policy instance

Insurance contract or identification number	C0004508479
Number of Individuals Covered	0
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150197

Policy instance

Insurance contract or identification number	10150197
Number of Individuals Covered	97
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $6,026
Total amount of fees paid to insurance company	USD $555
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $40,172
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,026
Insurance broker organization code?	3
Amount paid for insurance broker fees	555
Additional information about fees paid to insurance broker	OVERRIDES

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

03119

Policy instance

Insurance contract or identification number	03119
Number of Individuals Covered	48
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $1,770
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,770
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150195

Policy instance

Insurance contract or identification number	10150195
Number of Individuals Covered	111
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $374
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $374
Insurance broker organization code?	3

SECURITY HEALTH PLAN OF WISCONSIN, INC. (National Association of Insurance Commissioners NAIC id number: 96881 )

Policy contract number

C0004508479

Policy instance

Insurance contract or identification number	C0004508479
Number of Individuals Covered	102
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $9,099
Total amount of fees paid to insurance company	USD $0
Health 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 $9,099
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150197

Policy instance

Insurance contract or identification number	10150197
Number of Individuals Covered	111
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $5,652
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,652
Insurance broker organization code?	3

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

03119

Policy instance

Insurance contract or identification number	03119
Number of Individuals Covered	51
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $2,407
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 $2,407
Insurance broker organization code?	3

SECURITY HEALTH PLAN OF WISCONSIN, INC. (National Association of Insurance Commissioners NAIC id number: 96881 )

Policy contract number

C0004508480

Policy instance

Insurance contract or identification number	C0004508480
Number of Individuals Covered	2
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $27
Health 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 $27
Insurance broker organization code?	3

SECURITY HEALTH PLAN OF WISCONSIN, INC. (National Association of Insurance Commissioners NAIC id number: 96881 )

Policy contract number

C0004508482

Policy instance

Insurance contract or identification number	C0004508482
Number of Individuals Covered	0
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $378
Total amount of fees paid to insurance company	USD $0
Health 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 $378
Insurance broker organization code?	3

SECURITY HEALTH PLAN OF WISCONSIN, INC. (National Association of Insurance Commissioners NAIC id number: 96881 )

Policy contract number

C0004479039

Policy instance

Insurance contract or identification number	C0004479039
Number of Individuals Covered	0
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

BKRC17577

Policy instance

Insurance contract or identification number	BKRC17577
Number of Individuals Covered	65
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $2,260
Other welfare benefits provided	ACCIDENT; CRITIAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $21,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $18
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150196

Policy instance

Insurance contract or identification number	10150196
Number of Individuals Covered	13
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $568
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $568
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

8168

Policy instance

Insurance contract or identification number	8168
Number of Individuals Covered	108
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $310
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,192
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

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400150198

Policy instance

Insurance contract or identification number	400150198
Number of Individuals Covered	8
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $453
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY LIFE; VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $453
Insurance broker organization code?	3

SECURITY HEALTH PLAN OF WISCONSIN, INC. (National Association of Insurance Commissioners NAIC id number: 96881 )

Policy contract number

C0004508481

Policy instance

Insurance contract or identification number	C0004508481
Number of Individuals Covered	0
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $12,852
Health 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 $12,852
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150195

Policy instance

Insurance contract or identification number	10150195
Number of Individuals Covered	95
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $304
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $304
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400150198

Policy instance

Insurance contract or identification number	400150198
Number of Individuals Covered	26
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $708
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $708
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150196

Policy instance

Insurance contract or identification number	10150196
Number of Individuals Covered	4
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $299
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $299
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

8168

Policy instance

Insurance contract or identification number	8168
Number of Individuals Covered	93
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $345
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $345
Insurance broker organization code?	3

SECURITY HEALTH PLAN OF WISCONSIN, INC. (National Association of Insurance Commissioners NAIC id number: 96881 )

Policy contract number

C0004402514/5

Policy instance

Insurance contract or identification number	C0004402514/5
Number of Individuals Covered	109
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $23,907
Total amount of fees paid to insurance company	USD $0
Health 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 $23,907
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )

Policy contract number

BKRC17577

Policy instance

Insurance contract or identification number	BKRC17577
Number of Individuals Covered	139
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $15,314
Other welfare benefits provided	ACCIDENT AND CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $25,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,380
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150197

Policy instance

Insurance contract or identification number	10150197
Number of Individuals Covered	95
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $6,858
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,858
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150195

Policy instance

Insurance contract or identification number	10150195
Number of Individuals Covered	102
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $433
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

LG131

Policy instance

Insurance contract or identification number	LG131
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $2,370
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $19,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400150198

Policy instance

Insurance contract or identification number	400150198
Number of Individuals Covered	29
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $787
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150196

Policy instance

Insurance contract or identification number	10150196
Number of Individuals Covered	5
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $249
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SECURITY HEALTH PLAN OF WISCONSIN, INC. (National Association of Insurance Commissioners NAIC id number: 96881 )

Policy contract number

C0004402514/5

Policy instance

Insurance contract or identification number	C0004402514/5
Number of Individuals Covered	105
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $14,400
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10150197

Policy instance

Insurance contract or identification number	10150197
Number of Individuals Covered	102
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $6,461
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,071
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

8168

Policy instance

Insurance contract or identification number	8168
Number of Individuals Covered	83
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $297
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	BETHANY HOME, INC.
Employer identification number (EIN):	390868849
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1957-09-30
Company Identification Number:	167684