401k Plan data: DUBOIS CONTINUUM OF CARE WELFARE BENEFIT PLAN plan

DUBOIS CONTINUUM OF CARE WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	DUBOIS CONTINUUM OF CARE WELFARE BENEFIT PLAN
Plan identification number	502

DUBOIS CONTINUUM OF CARE WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision

401k Sponsoring company profile

DUBOIS CONTINUUM OF CARE has sponsored the creation of one or more 401k plans.

Company Name: DUBOIS CONTINUUM OF CARE

Employer identification number (EIN): 251352564

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DUBOIS CONTINUUM OF CARE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2018-03-01

Plan Statistics for DUBOIS CONTINUUM OF CARE WELFARE BENEFIT PLAN

401k plan membership statisitcs for DUBOIS CONTINUUM OF CARE WELFARE BENEFIT PLAN

Measure Date Value
2018: DUBOIS CONTINUUM OF CARE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-03-01 153
Total number of active participants reported on line 7a of the Form 5500 2018-03-01 135
Total of all active and inactive participants 2018-03-01 135
Total participants 2018-03-01 135

Measure	Date	Value
2018: DUBOIS CONTINUUM OF CARE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-03-01	153
Total number of active participants reported on line 7a of the Form 5500	2018-03-01	135
Total of all active and inactive participants	2018-03-01	135
Total participants	2018-03-01	135

Form 5500 Responses for DUBOIS CONTINUUM OF CARE WELFARE BENEFIT PLAN

2018: DUBOIS CONTINUUM OF CARE WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-03-01	Type of plan entity	Single employer plan
2018-03-01	Submission has been amended	No
2018-03-01	This submission is the final filing	No
2018-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-03-01	Plan is a collectively bargained plan	No
2018-03-01	Plan funding arrangement – Insurance	Yes
2018-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

237337

Policy instance

Insurance contract or identification number	237337
Number of Individuals Covered	124
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $26,167
Are there contracts with allocated funds for individual policies?	0
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 $849,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,167
Insurance broker organization code?	3

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

931

Policy instance

Insurance contract or identification number	931
Number of Individuals Covered	133
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $647
Are there contracts with allocated funds for individual policies?	0
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	Yes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $647
Insurance broker organization code?	3

DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )

Policy contract number

04696

Policy instance

Insurance contract or identification number	04696
Number of Individuals Covered	133
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $1,682
Total amount of fees paid to insurance company	USD $7,397
Are there contracts with allocated funds for individual policies?	0
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	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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,682
Insurance broker organization code?	3

Potentially related plans

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Company Name:	DUBOIS CONTINUUM OF CARE
Employer identification number (EIN):	251352564
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities