401k Plan data: REVOLUTIONARY CLINICS II, INC. HEALTH AND WELFARE BENEFIT PLAN plan

REVOLUTIONARY CLINICS II, INC. HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	REVOLUTIONARY CLINICS II, INC. HEALTH AND WELFARE BENEFIT PLAN
Plan identification number	501

REVOLUTIONARY CLINICS II, INC. HEALTH AND WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

REVOLUTIONARY CLINICS II, INC. has sponsored the creation of one or more 401k plans.

Company Name: REVOLUTIONARY CLINICS II, INC.

Employer identification number (EIN): 263198554

NAIC Classification: 111900
NAIC Description: Other Crop Farming

Form 5500 Filing Information

Submission information for form 5500 for 401k plan REVOLUTIONARY CLINICS II, INC. HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-04-01

Plan Statistics for REVOLUTIONARY CLINICS II, INC. HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for REVOLUTIONARY CLINICS II, INC. HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2020: REVOLUTIONARY CLINICS II, INC. HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-04-01 163
Total number of active participants reported on line 7a of the Form 5500 2020-04-01 236
Total of all active and inactive participants 2020-04-01 236
Total participants 2020-04-01 236

Measure	Date	Value
2020: REVOLUTIONARY CLINICS II, INC. HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-04-01	163
Total number of active participants reported on line 7a of the Form 5500	2020-04-01	236
Total of all active and inactive participants	2020-04-01	236
Total participants	2020-04-01	236

Form 5500 Responses for REVOLUTIONARY CLINICS II, INC. HEALTH AND WELFARE BENEFIT PLAN

2020: REVOLUTIONARY CLINICS II, INC. HEALTH AND WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-04-01	Type of plan entity	Single employer plan
2020-04-01	First time form 5500 has been submitted	Yes
2020-04-01	Submission has been amended	No
2020-04-01	This submission is the final filing	No
2020-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-04-01	Plan is a collectively bargained plan	No
2020-04-01	Plan funding arrangement – Insurance	Yes
2020-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

FALLON COMMUNITY HEALTH PLAN -MEDICARE (National Association of Insurance Commissioners NAIC id number: 95541 )

Policy contract number

C004518955C01

Policy instance

Insurance contract or identification number	C004518955C01
Number of Individuals Covered	185
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $25,089
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 $774,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FALLON HEALTH AND LIFE INSURANCE COMPANY - FHLAC (National Association of Insurance Commissioners NAIC id number: 66828 )

Policy contract number

C004518955C01

Policy instance

Insurance contract or identification number	C004518955C01
Number of Individuals Covered	51
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $8,180
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 $252,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ALTUS DENTAL INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 52632 )

Policy contract number

2284_1

Policy instance

Insurance contract or identification number	2284_1
Number of Individuals Covered	219
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $5,468
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
Welfare Benefit Premiums Paid to Carrier	USD $99,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	REVOLUTIONARY CLINICS II, INC.
Employer identification number (EIN):	263198554
NAIC Classification:	111900
NAIC Description:	Other Crop Farming