401k Plan data: CP SENIOR LIVING LLC WELFARE BENEFITS PLAN plan

CP SENIOR LIVING LLC WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	CP SENIOR LIVING LLC WELFARE BENEFITS PLAN
Plan identification number	501

CP SENIOR LIVING LLC WELFARE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

CP SENIOR LIVING LLC has sponsored the creation of one or more 401k plans.

Company Name: CP SENIOR LIVING LLC

Employer identification number (EIN): 873473577

NAIC Classification: 551112
NAIC Description: Offices of Other Holding Companies

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CP SENIOR LIVING LLC WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-12-01 SEAN BROADBENT 2023-06-06

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-12-01	SEAN BROADBENT	2023-06-06

Plan Statistics for CP SENIOR LIVING LLC WELFARE BENEFITS PLAN

401k plan membership statisitcs for CP SENIOR LIVING LLC WELFARE BENEFITS PLAN

Measure Date Value
2021: CP SENIOR LIVING LLC WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-12-01 116
Total number of active participants reported on line 7a of the Form 5500 2021-12-01 129
Number of retired or separated participants receiving benefits 2021-12-01 0
Number of other retired or separated participants entitled to future benefits 2021-12-01 0
Total of all active and inactive participants 2021-12-01 129
Number of employers contributing to the scheme 2021-12-01 0

Measure	Date	Value
2021: CP SENIOR LIVING LLC WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-12-01	116
Total number of active participants reported on line 7a of the Form 5500	2021-12-01	129
Number of retired or separated participants receiving benefits	2021-12-01	0
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	129
Number of employers contributing to the scheme	2021-12-01	0

Form 5500 Responses for CP SENIOR LIVING LLC WELFARE BENEFITS PLAN

2021: CP SENIOR LIVING LLC WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-12-01	Type of plan entity	Single employer plan
2021-12-01	Plan funding arrangement – Insurance	Yes
2021-12-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

98992381001

Policy instance

Insurance contract or identification number	98992381001
Number of Individuals Covered	111
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $630
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $630
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5931972

Policy instance

Insurance contract or identification number	5931972
Number of Individuals Covered	0
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $2,144
Total amount of fees paid to insurance company	USD $335
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,144
Amount paid for insurance broker fees	335
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

102242

Policy instance

Insurance contract or identification number	102242
Number of Individuals Covered	4
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $2,168
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,168
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

75669

Policy instance

Insurance contract or identification number	75669
Number of Individuals Covered	68
Insurance policy start date	2021-05-01
Insurance policy end date	2022-04-30
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
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL153479

Policy instance

Insurance contract or identification number	GL153479
Number of Individuals Covered	129
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $1,798
Total amount of fees paid to insurance company	USD $924
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $30,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,798
Amount paid for insurance broker fees	924
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

Potentially related plans

CP SENIOR LIVING 401(K) [EIN = 383906363]

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Company Name:	CP SENIOR LIVING LLC
Employer identification number (EIN):	873473577
NAIC Classification:	551112
NAIC Description:	Offices of Other Holding Companies