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DAUGHTERS OF SARAH SENIOR COMMUNITY 401k Plan overview

Plan NameDAUGHTERS OF SARAH SENIOR COMMUNITY
Plan identification number 505

DAUGHTERS OF SARAH SENIOR COMMUNITY Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Life insurance
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

DAUGHTERS OF SARAH NURSING CENTER INC. has sponsored the creation of one or more 401k plans.

Company Name:DAUGHTERS OF SARAH NURSING CENTER INC.
Employer identification number (EIN):237120570
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DAUGHTERS OF SARAH SENIOR COMMUNITY

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5052015-04-01ANN DEVOST ANN DEVOST2016-07-29
5052015-01-01ANN DEVOST ANN DEVOST2016-07-29
5052014-01-01COURTNEY MULSON
5052014-01-01COURTNEY MULSON
5052014-01-01COURTNEY MULSON
5052014-01-01COURTNEY MULSON
5052013-01-01CYNTHIA WAGNER
5052012-01-01COURTNEY MULSON CYNTHIA WAGNER2013-07-24
5052011-01-01CYNTHIA WAGNER COURTNEY MULSON2012-05-21
5052010-01-01COURTNEY MULSON CYNTHIA WAGNER2011-07-13
5052009-01-01CYNTHIA WAGNER COURTNEY MULSON2010-06-21
5052009-01-01CYNTHIA WAGNER COURTNEY MULSON2010-06-17

Plan Statistics for DAUGHTERS OF SARAH SENIOR COMMUNITY

401k plan membership statisitcs for DAUGHTERS OF SARAH SENIOR COMMUNITY

Measure Date Value
2015: DAUGHTERS OF SARAH SENIOR COMMUNITY 2015 401k membership
Total participants, beginning-of-year2015-04-01196
Total number of active participants reported on line 7a of the Form 55002015-04-01196
Total of all active and inactive participants2015-04-01196
Total participants2015-04-01196
Total participants, beginning-of-year2015-01-01196
Total number of active participants reported on line 7a of the Form 55002015-01-01196
Total of all active and inactive participants2015-01-01196
Total participants2015-01-01196
2014: DAUGHTERS OF SARAH SENIOR COMMUNITY 2014 401k membership
Total participants, beginning-of-year2014-01-01241
Total number of active participants reported on line 7a of the Form 55002014-01-01241
Total of all active and inactive participants2014-01-01241
Total participants2014-01-01241
2013: DAUGHTERS OF SARAH SENIOR COMMUNITY 2013 401k membership
Total participants, beginning-of-year2013-01-01234
Total number of active participants reported on line 7a of the Form 55002013-01-01242
Total of all active and inactive participants2013-01-01242
Total participants2013-01-01242
2012: DAUGHTERS OF SARAH SENIOR COMMUNITY 2012 401k membership
Total participants, beginning-of-year2012-01-01207
Total number of active participants reported on line 7a of the Form 55002012-01-01194
Total of all active and inactive participants2012-01-01194
Total participants2012-01-01194
2011: DAUGHTERS OF SARAH SENIOR COMMUNITY 2011 401k membership
Total participants, beginning-of-year2011-01-01199
Total number of active participants reported on line 7a of the Form 55002011-01-01199
Total of all active and inactive participants2011-01-01199
Total participants2011-01-01199
Number of participants with account balances2011-01-01207
2010: DAUGHTERS OF SARAH SENIOR COMMUNITY 2010 401k membership
Total participants, beginning-of-year2010-01-01231
Total number of active participants reported on line 7a of the Form 55002010-01-01199
Total of all active and inactive participants2010-01-01199
Total participants2010-01-01199
2009: DAUGHTERS OF SARAH SENIOR COMMUNITY 2009 401k membership
Total participants, beginning-of-year2009-01-01168
Total number of active participants reported on line 7a of the Form 55002009-01-01231
Total of all active and inactive participants2009-01-01231
Total participants2009-01-01231

Form 5500 Responses for DAUGHTERS OF SARAH SENIOR COMMUNITY

2015: DAUGHTERS OF SARAH SENIOR COMMUNITY 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01First time form 5500 has been submittedYes
2015-04-01Submission has been amendedNo
2015-04-01This submission is the final filingNo
2015-04-01This return/report is a short plan year return/report (less than 12 months)No
2015-04-01Plan is a collectively bargained planNo
2015-04-01Plan funding arrangement – General assets of the sponsorYes
2015-04-01Plan benefit arrangement – InsuranceYes
2015-01-01Type of plan entitySingle employer plan
2015-01-01First time form 5500 has been submittedYes
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: DAUGHTERS OF SARAH SENIOR COMMUNITY 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: DAUGHTERS OF SARAH SENIOR COMMUNITY 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: DAUGHTERS OF SARAH SENIOR COMMUNITY 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: DAUGHTERS OF SARAH SENIOR COMMUNITY 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: DAUGHTERS OF SARAH SENIOR COMMUNITY 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: DAUGHTERS OF SARAH SENIOR COMMUNITY 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedYes
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )
Policy contract numberG000AL7X
Policy instance 1
Insurance contract or identification numberG000AL7X
Number of Individuals Covered196
Insurance policy start date2015-04-01
Insurance policy end date2016-04-01
Total amount of commissions paid to insurance brokerUSD $528
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?Yes
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $5,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Other information about contractNON-EXPERIENCE RATED
Commission paid to Insurance BrokerUSD $528
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD
Insurance broker organization code?3
Insurance broker nameANCHOR AGENCY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL7X
Policy instance 1
Insurance contract or identification numberG000AL7X
Number of Individuals Covered196
Insurance policy start date2015-04-01
Insurance policy end date2016-04-01
Total amount of commissions paid to insurance brokerUSD $62
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?Yes
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Other information about contractNON-EXPERIENCE RATED
Commission paid to Insurance BrokerUSD $62
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD
Insurance broker organization code?3
Insurance broker nameANCHOR AGENCY INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract number
Policy instance 1
Number of Individuals Covered13
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $1,090
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?Yes
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )
Policy contract number
Policy instance 1
Number of Individuals Covered241
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $620
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?Yes
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,205
Amount paid for insurance broker fees1205
Insurance broker nameANCHOR AGENCY INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberGHA0AL7X
Policy instance 1
Insurance contract or identification numberGHA0AL7X
Number of Individuals Covered13
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $828
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $8,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL7X
Policy instance 1
Insurance contract or identification numberG000AL7X
Number of Individuals Covered242
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $75
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker nameANCHOR AGENCY

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