401k Plan data: WEIRTON GERIATRIC CENTER GENERAL WELFARE PLAN plan

WEIRTON GERIATRIC CENTER GENERAL WELFARE PLAN 401k Plan overview

Plan Name	WEIRTON GERIATRIC CENTER GENERAL WELFARE PLAN
Plan identification number	502

WEIRTON GERIATRIC CENTER GENERAL WELFARE PLAN Benefits

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

401k Sponsoring company profile

WEIRTON GERIATRIC CENTER has sponsored the creation of one or more 401k plans.

Company Name: WEIRTON GERIATRIC CENTER

Employer identification number (EIN): 550606587

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WEIRTON GERIATRIC CENTER GENERAL WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2021-12-01 RHONDA QUATTROCHI 2023-06-26

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2021-12-01	RHONDA QUATTROCHI	2023-06-26

Plan Statistics for WEIRTON GERIATRIC CENTER GENERAL WELFARE PLAN

401k plan membership statisitcs for WEIRTON GERIATRIC CENTER GENERAL WELFARE PLAN

Measure Date Value
2021: WEIRTON GERIATRIC CENTER GENERAL WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-12-01 187
Total number of active participants reported on line 7a of the Form 5500 2021-12-01 176
Number of retired or separated participants receiving benefits 2021-12-01 2
Number of other retired or separated participants entitled to future benefits 2021-12-01 0
Total of all active and inactive participants 2021-12-01 178

Measure	Date	Value
2021: WEIRTON GERIATRIC CENTER GENERAL WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-12-01	187
Total number of active participants reported on line 7a of the Form 5500	2021-12-01	176
Number of retired or separated participants receiving benefits	2021-12-01	2
Number of other retired or separated participants entitled to future benefits	2021-12-01	0
Total of all active and inactive participants	2021-12-01	178

Form 5500 Responses for WEIRTON GERIATRIC CENTER GENERAL WELFARE PLAN

2021: WEIRTON GERIATRIC CENTER GENERAL WELFARE PLAN 2021 form 5500 responses
2021-12-01	Type of plan entity	Single employer plan
2021-12-01	First time form 5500 has been submitted	Yes
2021-12-01	Submission has been amended	No
2021-12-01	This submission is the final filing	No
2021-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-12-01	Plan is a collectively bargained plan	No
2021-12-01	Plan funding arrangement – Insurance	Yes
2021-12-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00634357

Policy instance

Insurance contract or identification number	00634357
Number of Individuals Covered	125
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $26,572
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 $473,418
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	26572
Additional information about fees paid to insurance broker	SERVICE/GEN. AGENT FEES
Insurance broker organization code?	3

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

Policy contract number

7056

Policy instance

Insurance contract or identification number	7056
Number of Individuals Covered	176
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $1,276
Total amount of fees paid to insurance company	USD $26
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
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 $12,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,276
Insurance broker organization code?	3
Amount paid for insurance broker fees	26
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES

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

Policy contract number

70516

Policy instance

Insurance contract or identification number	70516
Number of Individuals Covered	176
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $170
Total amount of fees paid to insurance company	USD $4
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	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 $1,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $170
Insurance broker organization code?	3
Amount paid for insurance broker fees	4
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10191421001

Policy instance

Insurance contract or identification number	10191421001
Number of Individuals Covered	159
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $746
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 $10,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $746
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1101877

Policy instance

Insurance contract or identification number	1101877
Number of Individuals Covered	224
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $4,513
Total amount of fees paid to insurance company	USD $886
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 $47,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,706
Insurance broker organization code?	3
Amount paid for insurance broker fees	886
Additional information about fees paid to insurance broker	BONUS

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Company Name:	WEIRTON GERIATRIC CENTER
Employer identification number (EIN):	550606587
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities