401k Plan data: AMBASSADOR NURSING AND REHABILITATION CENTRE CRITICAL ILLNESS ACCIDENT AND VOLUNTARY SHORT TERM DISABILITY PLAN plan

AMBASSADOR NURSING AND REHABILITATION CENTRE CRITICAL ILLNESS ACCIDENT AND VOLUNTARY SHORT TERM DISABILITY PLAN 401k Plan overview

Plan Name	AMBASSADOR NURSING AND REHABILITATION CENTRE CRITICAL ILLNESS ACCIDENT AND VOLUNTARY SHORT TERM DISABILITY PLAN
Plan identification number	504

AMBASSADOR NURSING AND REHABILITATION CENTRE CRITICAL ILLNESS ACCIDENT AND VOLUNTARY SHORT TERM DISABILITY PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Temporary disability (accident and sickness) Other welfare benefit cover

401k Sponsoring company profile

MOROUN NURSING CENTER OF DETROIT, LLC has sponsored the creation of one or more 401k plans.

Company Name: MOROUN NURSING CENTER OF DETROIT, LLC

Employer identification number (EIN): 270166937

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

Additional information about MOROUN NURSING CENTER OF DETROIT, LLC

Jurisdiction of Incorporation: Michigan Department of Licensing & Regulatory Affairs

Incorporation Date:

Company Identification Number: D26246

More information about MOROUN NURSING CENTER OF DETROIT, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMBASSADOR NURSING AND REHABILITATION CENTRE CRITICAL ILLNESS ACCIDENT AND VOLUNTARY SHORT TERM DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
504 2018-05-01

Plan Statistics for AMBASSADOR NURSING AND REHABILITATION CENTRE CRITICAL ILLNESS ACCIDENT AND VOLUNTARY SHORT TERM DISABILITY PLAN

401k plan membership statisitcs for AMBASSADOR NURSING AND REHABILITATION CENTRE CRITICAL ILLNESS ACCIDENT AND VOLUNTARY SHORT TERM DISABILITY PLAN

Measure Date Value
2018: AMBASSADOR NURSING AND REHABILITATION CENTRE CRITICAL ILLNESS ACCIDENT AND VOLUNTARY SHORT TERM DISABILITY PLAN 2018 401k membership
Total participants, beginning-of-year 2018-05-01 104
Total number of active participants reported on line 7a of the Form 5500 2018-05-01 0
Number of retired or separated participants receiving benefits 2018-05-01 0
Number of other retired or separated participants entitled to future benefits 2018-05-01 0
Total of all active and inactive participants 2018-05-01 0

Measure	Date	Value
2018: AMBASSADOR NURSING AND REHABILITATION CENTRE CRITICAL ILLNESS ACCIDENT AND VOLUNTARY SHORT TERM DISABILITY PLAN 2018 401k membership
Total participants, beginning-of-year	2018-05-01	104
Total number of active participants reported on line 7a of the Form 5500	2018-05-01	0
Number of retired or separated participants receiving benefits	2018-05-01	0
Number of other retired or separated participants entitled to future benefits	2018-05-01	0
Total of all active and inactive participants	2018-05-01	0

Form 5500 Responses for AMBASSADOR NURSING AND REHABILITATION CENTRE CRITICAL ILLNESS ACCIDENT AND VOLUNTARY SHORT TERM DISABILITY PLAN

2018: AMBASSADOR NURSING AND REHABILITATION CENTRE CRITICAL ILLNESS ACCIDENT AND VOLUNTARY SHORT TERM DISABILITY PLAN 2018 form 5500 responses
2018-05-01	Type of plan entity	Single employer plan
2018-05-01	First time form 5500 has been submitted	Yes
2018-05-01	Submission has been amended	No
2018-05-01	This submission is the final filing	Yes
2018-05-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2018-05-01	Plan is a collectively bargained plan	No
2018-05-01	Plan funding arrangement – Insurance	Yes
2018-05-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

0010585806

Policy instance

Insurance contract or identification number	0010585806
Number of Individuals Covered	75
Insurance policy start date	2018-05-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $16,357
Total amount of fees paid to insurance company	USD $1,782
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	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	GROUP CRITICAL ILLNESS GROUP ACCIDENT AND HOSPITAL INDEMNITY
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 $41,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,863
Amount paid for insurance broker fees	1541
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0010585806

Policy instance

Insurance contract or identification number	0010585806
Number of Individuals Covered	75
Insurance policy start date	2018-05-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $37,878
Total amount of fees paid to insurance company	USD $3,739
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	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	INDIVIDUAL SHORT TERM DISABILITY AND WHOLE LIFE
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 $63,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,430
Amount paid for insurance broker fees	3485
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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Company Name:	MOROUN NURSING CENTER OF DETROIT, LLC
Employer identification number (EIN):	270166937
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Michigan Department of Licensing & Regulatory Affairs
Incorporation Date:
Company Identification Number:	D26246