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| Plan Name | REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | REVIVE HEALTH SENIOR CENTER, LLC |
| Employer identification number (EIN): | 832504049 |
| NAIC Classification: | 111100 |
| NAIC Description: | Oilseed and Grain Farming |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2022-02-01 | CHELSEY GRAY | 2023-08-04 | ||
| 501 | 2021-02-01 | CHELSEY GRAY | 2022-09-19 |
| Measure | Date | Value |
|---|---|---|
| 2022: REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN 2022 401k membership | ||
| Total participants, beginning-of-year | 2022-02-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-02-01 | 285 |
| Number of retired or separated participants receiving benefits | 2022-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-02-01 | 0 |
| Total of all active and inactive participants | 2022-02-01 | 285 |
| Number of employers contributing to the scheme | 2022-02-01 | 0 |
| 2021: REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN 2021 401k membership | ||
| Total participants, beginning-of-year | 2021-02-01 | 105 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-02-01 | 120 |
| Number of retired or separated participants receiving benefits | 2021-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-02-01 | 0 |
| Total of all active and inactive participants | 2021-02-01 | 120 |
| Number of employers contributing to the scheme | 2021-02-01 | 0 |
| 2022: REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN 2022 form 5500 responses | ||
|---|---|---|
| 2022-02-01 | Type of plan entity | Single employer plan |
| 2022-02-01 | Plan funding arrangement – Insurance | Yes |
| 2022-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN 2021 form 5500 responses | ||
| 2021-02-01 | Type of plan entity | Single employer plan |
| 2021-02-01 | First time form 5500 has been submitted | Yes |
| 2021-02-01 | Plan funding arrangement – Insurance | Yes |
| 2021-02-01 | Plan benefit arrangement – Insurance | Yes |
| ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 ) | |||||||||||||||||||||||||||||||||
| Policy contract number | L05139 | ||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||
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| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 95473 ) | |||||||||||||||||||||||||||||||||
| Policy contract number | L05139 | ||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) | |||||||||||||||||||||||||||||||||
| Policy contract number | GLUG0C3G6 | ||||||||||||||||||||||||||||||||
| Policy instance | 3 | ||||||||||||||||||||||||||||||||
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| HOMETOWN HEALTH (National Association of Insurance Commissioners NAIC id number: 48305 ) | |||||||||||||||||||||||||||||||||
| Policy contract number | 4451P | ||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) | |||||||||||||||||||||||||||||||||
| Policy contract number | 010-050106 | ||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) | |||||||||||||||||||||||||||||||||
| Policy contract number | 5957822 | ||||||||||||||||||||||||||||||||
| Policy instance | 3 | ||||||||||||||||||||||||||||||||
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