401k Plan data: BETH SHOLOM LIFECARE COMMUNITY DENTAL PLAN plan

BETH SHOLOM LIFECARE COMMUNITY DENTAL PLAN 401k Plan overview

Plan Name	BETH SHOLOM LIFECARE COMMUNITY DENTAL PLAN
Plan identification number	517

BETH SHOLOM LIFECARE COMMUNITY DENTAL PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Dental Long-term disability cover

401k Sponsoring company profile

BETH SHOLOM HOME OF VIRGINIA has sponsored the creation of one or more 401k plans.

Company Name: BETH SHOLOM HOME OF VIRGINIA

Employer identification number (EIN): 540525702

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

Additional information about BETH SHOLOM HOME OF VIRGINIA

Jurisdiction of Incorporation: Virginia Secretary of State

Incorporation Date: 1945-04-27

Company Identification Number: 0051264

Legal Registered Office Address: 1600 JOHN ROLFE PKWY
PO BOX 1998
RICHMOND
United States of America (USA)
23233

More information about BETH SHOLOM HOME OF VIRGINIA

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BETH SHOLOM LIFECARE COMMUNITY DENTAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
517 2019-02-01

Plan Statistics for BETH SHOLOM LIFECARE COMMUNITY DENTAL PLAN

401k plan membership statisitcs for BETH SHOLOM LIFECARE COMMUNITY DENTAL PLAN

Measure Date Value
2019: BETH SHOLOM LIFECARE COMMUNITY DENTAL PLAN 2019 401k membership
Total participants, beginning-of-year 2019-02-01 150
Total number of active participants reported on line 7a of the Form 5500 2019-02-01 0
Number of retired or separated participants receiving benefits 2019-02-01 0
Number of other retired or separated participants entitled to future benefits 2019-02-01 0
Total of all active and inactive participants 2019-02-01 0

Measure	Date	Value
2019: BETH SHOLOM LIFECARE COMMUNITY DENTAL PLAN 2019 401k membership
Total participants, beginning-of-year	2019-02-01	150
Total number of active participants reported on line 7a of the Form 5500	2019-02-01	0
Number of retired or separated participants receiving benefits	2019-02-01	0
Number of other retired or separated participants entitled to future benefits	2019-02-01	0
Total of all active and inactive participants	2019-02-01	0

Form 5500 Responses for BETH SHOLOM LIFECARE COMMUNITY DENTAL PLAN

2019: BETH SHOLOM LIFECARE COMMUNITY DENTAL PLAN 2019 form 5500 responses
2019-02-01	Type of plan entity	Single employer plan
2019-02-01	First time form 5500 has been submitted	Yes
2019-02-01	Submission has been amended	No
2019-02-01	This submission is the final filing	Yes
2019-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-02-01	Plan is a collectively bargained plan	No
2019-02-01	Plan funding arrangement – Insurance	Yes
2019-02-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

G1400

Policy instance

Insurance contract or identification number	G1400
Number of Individuals Covered	139
Insurance policy start date	2019-02-01
Insurance policy end date	2020-01-31
Total amount of commissions paid to insurance broker	USD $7,030
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	Yes
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 $40,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,030
Insurance broker organization code?	3

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )

Policy contract number

VA3087

Policy instance

Insurance contract or identification number	VA3087
Number of Individuals Covered	93
Insurance policy start date	2019-02-01
Insurance policy end date	2020-01-31
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 $46,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	BETH SHOLOM HOME OF VIRGINIA
Employer identification number (EIN):	540525702
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Virginia Secretary of State
Incorporation Date:	1945-04-27
Company Identification Number:	0051264
Legal Registered Office Address:	1600 JOHN ROLFE PKWY PO BOX 1998 RICHMOND United States of America (USA) 23233