401k Plan data: PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN plan

PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN
Plan identification number	501

PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN Benefits

401k Plan Type

Welfare Benefit

Plan Features/Benefits

Health (other than dental or vision)
Life insurance
Dental
Vision
Long-term disability cover
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.
Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

PACIFIC LODGE YOUTH SERVICES, INC. has sponsored the creation of one or more 401k plans.

Company Name: PACIFIC LODGE YOUTH SERVICES, INC.

Employer identification number (EIN): 951691300

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-03-01 CHARLES BEST
501 2012-03-01 OLGA DIAZ

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2015-03-01	CHARLES BEST
501	2012-03-01	OLGA DIAZ

Plan Statistics for PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN

401k plan membership statisitcs for PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN

Measure Date Value
2015: PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-03-01 102
Total number of active participants reported on line 7a of the Form 5500 2015-03-01 103
Number of retired or separated participants receiving benefits 2015-03-01 0
Number of other retired or separated participants entitled to future benefits 2015-03-01 0
Total of all active and inactive participants 2015-03-01 103
2012: PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-03-01 103
Total number of active participants reported on line 7a of the Form 5500 2012-03-01 93
Number of retired or separated participants receiving benefits 2012-03-01 0
Number of other retired or separated participants entitled to future benefits 2012-03-01 0
Total of all active and inactive participants 2012-03-01 93

Measure	Date	Value
2015: PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-03-01	102
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	103
Number of retired or separated participants receiving benefits	2015-03-01	0
Number of other retired or separated participants entitled to future benefits	2015-03-01	0
Total of all active and inactive participants	2015-03-01	103
2012: PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-03-01	103
Total number of active participants reported on line 7a of the Form 5500	2012-03-01	93
Number of retired or separated participants receiving benefits	2012-03-01	0
Number of other retired or separated participants entitled to future benefits	2012-03-01	0
Total of all active and inactive participants	2012-03-01	93

Form 5500 Responses for PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN

2015: PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Submission has been amended	No
2015-03-01	This submission is the final filing	No
2015-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-03-01	Plan is a collectively bargained plan	No
2015-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2012: PACIFIC LODGE YOUTH SERVICES, INC. WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-03-01	Type of plan entity	Single employer plan
2012-03-01	First time form 5500 has been submitted	Yes
2012-03-01	Submission has been amended	No
2012-03-01	This submission is the final filing	No
2012-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-03-01	Plan is a collectively bargained plan	No
2012-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

154574

Policy instance

Insurance contract or identification number	154574
Number of Individuals Covered	103
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $233
Total amount of fees paid to insurance company	USD $91
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $233
Insurance broker organization code?	3
Amount paid for insurance broker fees	91
Additional information about fees paid to insurance broker	BONUS, OVERRIDE AND NON MONETARY COMPENSATION
Insurance broker name	WARNER PACIFIC INSURANCE SERVICES

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

154574

Policy instance

Insurance contract or identification number	154574
Number of Individuals Covered	57
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $22,488
Total amount of fees paid to insurance company	USD $8,803
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $433,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,488
Insurance broker organization code?	3
Amount paid for insurance broker fees	8803
Additional information about fees paid to insurance broker	BONUS, OVERRIDE AND NON MONETARY COMPENSATION
Insurance broker name	WARNER PACIFIC INSURANCE SERVICES

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

154574

Policy instance

Insurance contract or identification number	154574
Number of Individuals Covered	74
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $18,762
Total amount of fees paid to insurance company	USD $6,166
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $368,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,762
Insurance broker organization code?	3
Amount paid for insurance broker fees	6166
Additional information about fees paid to insurance broker	BONUS, OVERRIDE AND NON MONETARY COMPENSATION
Insurance broker name	WARNER PACIFIC INSURANCE SVCS.

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

Policy contract number

00475629

Policy instance

Insurance contract or identification number	00475629
Number of Individuals Covered	76
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $5,994
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $52,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,583
Insurance broker organization code?	3
Insurance broker name	PACIFIC ADVISORS INC.

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

154574

Policy instance

Insurance contract or identification number	154574
Number of Individuals Covered	103
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $144
Total amount of fees paid to insurance company	USD $47
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $144
Insurance broker organization code?	3
Amount paid for insurance broker fees	47
Additional information about fees paid to insurance broker	BONUS, OVERRIDE AND NON MONETARY COMPENSATION
Insurance broker name	WARNER PACIFIC INSURANCE SVCS.

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

Policy contract number

00475629

Policy instance

Insurance contract or identification number	00475629
Number of Individuals Covered	76
Insurance policy start date	2013-02-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $480
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $471
Insurance broker organization code?	3
Insurance broker name	PACIFIC ADVISORS INC.

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Company Name:	PACIFIC LODGE YOUTH SERVICES, INC.
Employer identification number (EIN):	951691300
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities