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REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameREVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN
Plan identification number 501

REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

REVIVE HEALTH SENIOR CENTER, LLC has sponsored the creation of one or more 401k plans.

Company Name:REVIVE HEALTH SENIOR CENTER, LLC
Employer identification number (EIN):832504049
NAIC Classification:111100
NAIC Description:Oilseed and Grain Farming

Form 5500 Filing Information

Submission information for form 5500 for 401k plan REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-02-01CHELSEY GRAY2023-08-04
5012021-02-01CHELSEY GRAY2022-09-19

Plan Statistics for REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN

Measure Date Value
2022: REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-02-01120
Total number of active participants reported on line 7a of the Form 55002022-02-01285
Number of retired or separated participants receiving benefits2022-02-010
Number of other retired or separated participants entitled to future benefits2022-02-010
Total of all active and inactive participants2022-02-01285
Number of employers contributing to the scheme2022-02-010
2021: REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-02-01105
Total number of active participants reported on line 7a of the Form 55002021-02-01120
Number of retired or separated participants receiving benefits2021-02-010
Number of other retired or separated participants entitled to future benefits2021-02-010
Total of all active and inactive participants2021-02-01120
Number of employers contributing to the scheme2021-02-010

Form 5500 Responses for REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN

2022: REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-02-01Type of plan entitySingle employer plan
2022-02-01Plan funding arrangement – InsuranceYes
2022-02-01Plan benefit arrangement – InsuranceYes
2021: REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-02-01Type of plan entitySingle employer plan
2021-02-01First time form 5500 has been submittedYes
2021-02-01Plan funding arrangement – InsuranceYes
2021-02-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )
Policy contract numberL05139
Policy instance 1
Insurance contract or identification numberL05139
Number of Individuals Covered105
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $17,180
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $497,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,180
Amount paid for insurance broker fees0
Insurance broker organization code?3
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 95473 )
Policy contract numberL05139
Policy instance 2
Insurance contract or identification numberL05139
Number of Individuals Covered140
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $19,932
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $577,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,932
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0C3G6
Policy instance 3
Insurance contract or identification numberGLUG0C3G6
Number of Individuals Covered285
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $7,323
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $104,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,323
Amount paid for insurance broker fees0
Insurance broker organization code?3
HOMETOWN HEALTH (National Association of Insurance Commissioners NAIC id number: 48305 )
Policy contract number4451P
Policy instance 1
Insurance contract or identification number4451P
Number of Individuals Covered70
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $612,316
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-050106
Policy instance 2
Insurance contract or identification number010-050106
Number of Individuals Covered176
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $9,051
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $90,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,051
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5957822
Policy instance 3
Insurance contract or identification number5957822
Number of Individuals Covered104
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $377
Total amount of fees paid to insurance companyUSD $63
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $2,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $377
Amount paid for insurance broker fees17
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3

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