401k Plan data: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN plan

TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 401k Plan overview

Plan Name	TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN
Plan identification number	001

TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

KINGSTON NH OPERATIONS LLC has sponsored the creation of one or more 401k plans.

Company Name: KINGSTON NH OPERATIONS LLC

Employer identification number (EIN): 823092720

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01
001 2021-01-01
001 2020-01-01
001 2019-01-01

Plan Statistics for TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN

401k plan membership statisitcs for TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN

Measure Date Value
2022: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 204
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 198
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 2
Total of all active and inactive participants 2022-01-01 200
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 200
Number of participants with account balances 2022-01-01 81
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 4
2021: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 229
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 193
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 16
Total of all active and inactive participants 2021-01-01 209
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 209
Number of participants with account balances 2021-01-01 91
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 45
2020: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 233
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 267
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 8
Total of all active and inactive participants 2020-01-01 275
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 275
Number of participants with account balances 2020-01-01 87
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 229
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 218
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 6
Total of all active and inactive participants 2019-01-01 224
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 224
Number of participants with account balances 2019-01-01 68
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 5

Measure	Date	Value
2022: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	204
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	198
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	2
Total of all active and inactive participants	2022-01-01	200
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	200
Number of participants with account balances	2022-01-01	81
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	4
2021: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	229
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	193
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	16
Total of all active and inactive participants	2021-01-01	209
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	209
Number of participants with account balances	2021-01-01	91
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	45
2020: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	233
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	267
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	8
Total of all active and inactive participants	2020-01-01	275
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	275
Number of participants with account balances	2020-01-01	87
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	229
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	218
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	6
Total of all active and inactive participants	2019-01-01	224
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	224
Number of participants with account balances	2019-01-01	68
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	5

Financial Data on TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN

Measure	Date	Value
2022 : TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2022 401k financial data
Total income from all sources (including contributions)	2022-12-31	$191,396
Total of all expenses incurred	2022-12-31	$232,263
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$205,609
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$529,859
Value of total assets at end of year	2022-12-31	$2,294,857
Value of total assets at beginning of year	2022-12-31	$2,335,724
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$26,654
Total interest from all sources	2022-12-31	$1,467
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$233,575
If this is an individual account plan, was there a blackout period	2022-12-31	Yes
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$345,091
Participant contributions at end of year	2022-12-31	$34,844
Participant contributions at beginning of year	2022-12-31	$16,012
Participant contributions at beginning of year	2022-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$65,083
Total non interest bearing cash at beginning of year	2022-12-31	$1,692
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-40,867
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$2,294,857
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$2,335,724
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Investment advisory and management fees	2022-12-31	$26,654
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$28,819
Value of interest in pooled separate accounts at end of year	2022-12-31	$2,231,194
Value of interest in pooled separate accounts at beginning of year	2022-12-31	$2,318,020
Interest on participant loans	2022-12-31	$1,467
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-462
Net investment gain/loss from pooled separate accounts	2022-12-31	$-339,468
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$119,685
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$205,609
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2022-12-31	Yes
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	RICHARDS, MITCHELL & CROSS PA
Accountancy firm EIN	2022-12-31	464063801
2021 : TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2021 401k financial data
Total income from all sources (including contributions)	2021-12-31	$849,144
Total of all expenses incurred	2021-12-31	$70,384
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$46,532
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$580,415
Value of total assets at end of year	2021-12-31	$2,335,724
Value of total assets at beginning of year	2021-12-31	$1,556,964
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$23,852
Total interest from all sources	2021-12-31	$363
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$233,572
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$343,312
Participant contributions at end of year	2021-12-31	$16,012
Participant contributions at beginning of year	2021-12-31	$4,327
Participant contributions at end of year	2021-12-31	$0
Participant contributions at beginning of year	2021-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$116,842
Total non interest bearing cash at end of year	2021-12-31	$1,692
Total non interest bearing cash at beginning of year	2021-12-31	$1,692
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$778,760
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$2,335,724
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$1,556,964
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Investment advisory and management fees	2021-12-31	$23,852
Value of interest in pooled separate accounts at end of year	2021-12-31	$2,318,020
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$1,550,945
Interest on participant loans	2021-12-31	$363
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$268,366
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$120,261
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$46,532
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	FASTEN HALBERTSTAM LLP
Accountancy firm EIN	2021-12-31	472319109
2020 : TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2020 401k financial data
Total transfer of assets to this plan	2020-12-31	$0
Total transfer of assets from this plan	2020-12-31	$0
Expenses. Interest paid	2020-12-31	$0
Amount of participant contributions which was failed to transmit to the plan within the time period described in 29 CFR 251.3-102	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$564,197
Total of all expenses incurred	2020-12-31	$144,793
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$131,971
Expenses. Certain deemed distributions of participant loans	2020-12-31	$0
Value of total corrective distributions	2020-12-31	$212
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$375,995
Value of total assets at end of year	2020-12-31	$1,556,964
Value of total assets at beginning of year	2020-12-31	$1,137,560
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$12,610
Total interest from all sources	2020-12-31	$218
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Administrative expenses professional fees incurred	2020-12-31	$3,512
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$155,696
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$276,013
Participant contributions at end of year	2020-12-31	$4,327
Participant contributions at beginning of year	2020-12-31	$3,831
Participant contributions at end of year	2020-12-31	$0
Participant contributions at beginning of year	2020-12-31	$424
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$0
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2020-12-31	$0
Administrative expenses (other) incurred	2020-12-31	$0
Total non interest bearing cash at end of year	2020-12-31	$1,692
Total non interest bearing cash at beginning of year	2020-12-31	$1,316
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Income. Non cash contributions	2020-12-31	$0
Value of net income/loss	2020-12-31	$419,404
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$1,556,964
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$1,137,560
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Investment advisory and management fees	2020-12-31	$632
Value of interest in pooled separate accounts at end of year	2020-12-31	$1,550,945
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$1,131,989
Interest on participant loans	2020-12-31	$218
Expenses. Payments to insurance carriers foe the provision of benefits	2020-12-31	$0
Net investment gain/loss from pooled separate accounts	2020-12-31	$187,984
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$99,982
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$131,971
Contract administrator fees	2020-12-31	$8,466
Did the plan have assets held for investment	2020-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Unqualified
Accountancy firm name	2020-12-31	FASTEN HALBERSTAM LLP
Accountancy firm EIN	2020-12-31	472319109
2019 : TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2019 401k financial data
Total transfer of assets to this plan	2019-12-31	$0
Total transfer of assets from this plan	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$1,274,141
Total of all expenses incurred	2019-12-31	$136,581
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$126,704
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$1,110,291
Value of total assets at end of year	2019-12-31	$1,137,560
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$9,877
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Administrative expenses professional fees incurred	2019-12-31	$2,857
Was this plan covered by a fidelity bond	2019-12-31	No
If this is an individual account plan, was there a blackout period	2019-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$205,038
Participant contributions at end of year	2019-12-31	$3,831
Participant contributions at end of year	2019-12-31	$424
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$821,340
Total non interest bearing cash at end of year	2019-12-31	$1,316
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Income. Non cash contributions	2019-12-31	$0
Value of net income/loss	2019-12-31	$1,137,560
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$1,137,560
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Investment advisory and management fees	2019-12-31	$481
Value of interest in pooled separate accounts at end of year	2019-12-31	$1,131,989
Net investment gain/loss from pooled separate accounts	2019-12-31	$163,850
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Contributions received in cash from employer	2019-12-31	$83,913
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$126,704
Contract administrator fees	2019-12-31	$6,539
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	FASTEN HALBERSTAM LLP
Accountancy firm EIN	2019-12-31	472319109

Form 5500 Responses for TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN

2022: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: TEN BROECK CENTER FOR REHABILITATION & NURSING 401(K) PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	First time form 5500 has been submitted	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 86375 )

Policy contract number

802097

Policy instance

Insurance contract or identification number	802097
Number of Individuals Covered	0
Insurance policy start date	2022-01-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $1,016
Total amount of fees paid to insurance company	USD $9,426
Commission paid to Insurance Broker	USD $1,016
Amount paid for insurance broker fees	9426
Additional information about fees paid to insurance broker	FEES AND COMMISSIONS PAID (TPA FEES)
Insurance broker organization code?	5

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

Policy contract number

823828

Policy instance

Insurance contract or identification number	823828
Number of Individuals Covered	216
Insurance policy start date	2022-11-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

JOHN HANCOCK LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 86375 )

Policy contract number

Policy instance

Number of Individuals Covered	92
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,047
Total amount of fees paid to insurance company	USD $6,729
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Commission paid to Insurance Broker	USD $6,729
Insurance broker organization code?	5

JOHN HANCOCK LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 86375 )

Policy contract number

Policy instance

Number of Individuals Covered	87
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,077
Total amount of fees paid to insurance company	USD $4,130
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	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 $0
Amount paid for insurance broker fees	4130
Insurance broker organization code?	5

JOHN HANCOCK LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 86375 )

Policy contract number

Policy instance

Number of Individuals Covered	70
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,216
Total amount of fees paid to insurance company	USD $7,877
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	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 $0
Amount paid for insurance broker fees	7877
Insurance broker organization code?	5

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Company Name:	KINGSTON NH OPERATIONS LLC
Employer identification number (EIN):	823092720
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities