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OAK RIDGE CARE CENTER, INC. WRAP PLAN 401k Plan overview

Plan NameOAK RIDGE CARE CENTER, INC. WRAP PLAN
Plan identification number 507

OAK RIDGE CARE CENTER, INC. WRAP PLAN Benefits

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

OAK RIDGE CARE CENTER, INC has sponsored the creation of one or more 401k plans.

Company Name:OAK RIDGE CARE CENTER, INC
Employer identification number (EIN):391081647
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OAK RIDGE CARE CENTER, INC. WRAP PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5072021-01-01
5072021-01-01

Plan Statistics for OAK RIDGE CARE CENTER, INC. WRAP PLAN

401k plan membership statisitcs for OAK RIDGE CARE CENTER, INC. WRAP PLAN

Measure Date Value
2021: OAK RIDGE CARE CENTER, INC. WRAP PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01107
Total number of active participants reported on line 7a of the Form 55002021-01-0187
Total of all active and inactive participants2021-01-0187

Form 5500 Responses for OAK RIDGE CARE CENTER, INC. WRAP PLAN

2021: OAK RIDGE CARE CENTER, INC. WRAP PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01First time form 5500 has been submittedYes
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number168413
Policy instance 1
Insurance contract or identification number168413
Number of Individuals Covered80
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,258
Total amount of fees paid to insurance companyUSD $272
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,258
Insurance broker organization code?3
Amount paid for insurance broker fees272
Additional information about fees paid to insurance brokerADMINISTRATION
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number168413
Policy instance 5
Insurance contract or identification number168413
Number of Individuals Covered18
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,060
Total amount of fees paid to insurance companyUSD $497
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,060
Insurance broker organization code?3
Amount paid for insurance broker fees497
Additional information about fees paid to insurance brokerADMINISTRATION
DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )
Policy contract number02921
Policy instance 4
Insurance contract or identification number02921
Number of Individuals Covered14
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $476
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $476
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number168413
Policy instance 3
Insurance contract or identification number168413
Number of Individuals Covered80
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,258
Total amount of fees paid to insurance companyUSD $272
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,258
Insurance broker organization code?3
Amount paid for insurance broker fees272
Additional information about fees paid to insurance brokerADMINISTRATION
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number168413
Policy instance 2
Insurance contract or identification number168413
Number of Individuals Covered34
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $6,907
Total amount of fees paid to insurance companyUSD $553
Other welfare benefits providedACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $13,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,034
Insurance broker organization code?3
Amount paid for insurance broker fees553
Additional information about fees paid to insurance brokerADMINISTRATION
DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )
Policy contract number03021
Policy instance 1
Insurance contract or identification number03021
Number of Individuals Covered31
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,487
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,487
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number168413
Policy instance 6
Insurance contract or identification number168413
Number of Individuals Covered18
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,060
Total amount of fees paid to insurance companyUSD $497
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,060
Insurance broker organization code?3
Amount paid for insurance broker fees497
Additional information about fees paid to insurance brokerADMINISTRATION
DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )
Policy contract number03021
Policy instance 5
Insurance contract or identification number03021
Number of Individuals Covered31
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,487
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,487
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number168413
Policy instance 4
Insurance contract or identification number168413
Number of Individuals Covered34
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $6,907
Total amount of fees paid to insurance companyUSD $553
Other welfare benefits providedACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $13,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,034
Insurance broker organization code?3
Amount paid for insurance broker fees553
Additional information about fees paid to insurance brokerADMINISTRATION
DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )
Policy contract number02921
Policy instance 3
Insurance contract or identification number02921
Number of Individuals Covered14
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $476
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $476
Insurance broker organization code?3
WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 )
Policy contract number44047
Policy instance 2
Insurance contract or identification number44047
Number of Individuals Covered37
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $406
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $406
Insurance broker organization code?3
WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 )
Policy contract number44047
Policy instance 6
Insurance contract or identification number44047
Number of Individuals Covered37
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $406
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $406
Insurance broker organization code?3

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