401k Plan data: SUMMERFORD HEALTH AND REHAB, LLC plan

SUMMERFORD HEALTH AND REHAB, LLC 401k Plan overview

Plan Name	SUMMERFORD HEALTH AND REHAB, LLC
Plan identification number	501

SUMMERFORD HEALTH AND REHAB, LLC Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Death benefits (include travel accident but not life insurance) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

SUMMERFORD NURSING HOME INC has sponsored the creation of one or more 401k plans.

Company Name: SUMMERFORD NURSING HOME INC

Employer identification number (EIN): 852598357

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SUMMERFORD HEALTH AND REHAB, LLC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-07-01 GITTY LIPSCHITZ 2023-02-28
501 2020-07-01 GITTY LIPSCHITZ 2022-04-18

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-07-01	GITTY LIPSCHITZ	2023-02-28
501	2020-07-01	GITTY LIPSCHITZ	2022-04-18

Plan Statistics for SUMMERFORD HEALTH AND REHAB, LLC

401k plan membership statisitcs for SUMMERFORD HEALTH AND REHAB, LLC

Measure Date Value
2021: SUMMERFORD HEALTH AND REHAB, LLC 2021 401k membership
Total participants, beginning-of-year 2021-07-01 100
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 80
Number of retired or separated participants receiving benefits 2021-07-01 0
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 80
Number of employers contributing to the scheme 2021-07-01 0
2020: SUMMERFORD HEALTH AND REHAB, LLC 2020 401k membership
Total participants, beginning-of-year 2020-07-01 100
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 108
Number of retired or separated participants receiving benefits 2020-07-01 0
Number of other retired or separated participants entitled to future benefits 2020-07-01 0
Total of all active and inactive participants 2020-07-01 108
Number of employers contributing to the scheme 2020-07-01 0

Measure	Date	Value
2021: SUMMERFORD HEALTH AND REHAB, LLC 2021 401k membership
Total participants, beginning-of-year	2021-07-01	100
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	80
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	80
Number of employers contributing to the scheme	2021-07-01	0
2020: SUMMERFORD HEALTH AND REHAB, LLC 2020 401k membership
Total participants, beginning-of-year	2020-07-01	100
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	108
Number of retired or separated participants receiving benefits	2020-07-01	0
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	108
Number of employers contributing to the scheme	2020-07-01	0

Form 5500 Responses for SUMMERFORD HEALTH AND REHAB, LLC

2021: SUMMERFORD HEALTH AND REHAB, LLC 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2020: SUMMERFORD HEALTH AND REHAB, LLC 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	First time form 5500 has been submitted	Yes
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

473833

Policy instance

Insurance contract or identification number	473833
Number of Individuals Covered	80
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $5,236
Total amount of fees paid to insurance company	USD $1,960
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $53,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,236
Amount paid for insurance broker fees	1960
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

473833

Policy instance

Insurance contract or identification number	473833
Number of Individuals Covered	108
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $10,004
Total amount of fees paid to insurance company	USD $610
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $98,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,718
Amount paid for insurance broker fees	610
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )

Policy contract number

0036638

Policy instance

Insurance contract or identification number	0036638
Number of Individuals Covered	123
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SUMMERFORD NURSING HOME INC
Employer identification number (EIN):	852598357
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities