401k Plan data: CAPITOL HOME HEALTH - HEALTH AND WELFARE PLAN plan

CAPITOL HOME HEALTH - HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	CAPITOL HOME HEALTH - HEALTH AND WELFARE PLAN
Plan identification number	501

CAPITOL HOME HEALTH - HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) 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.

401k Sponsoring company profile

CAPITOL HOME HEALTH has sponsored the creation of one or more 401k plans.

Company Name: CAPITOL HOME HEALTH

Employer identification number (EIN): 272266477

NAIC Classification: 621610
NAIC Description: Home Health Care Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CAPITOL HOME HEALTH - HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-10-01 GILLIAN JACOB 2021-04-13
501 2019-10-01 GILLIAN JACOB 2024-06-28

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2019-10-01	GILLIAN JACOB	2021-04-13
501	2019-10-01	GILLIAN JACOB	2024-06-28

Plan Statistics for CAPITOL HOME HEALTH - HEALTH AND WELFARE PLAN

401k plan membership statisitcs for CAPITOL HOME HEALTH - HEALTH AND WELFARE PLAN

Measure Date Value
2019: CAPITOL HOME HEALTH - HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-10-01 119
Total number of active participants reported on line 7a of the Form 5500 2019-10-01 92
Number of retired or separated participants receiving benefits 2019-10-01 5
Number of other retired or separated participants entitled to future benefits 2019-10-01 44
Total of all active and inactive participants 2019-10-01 141
Number of employers contributing to the scheme 2019-10-01 0

Measure	Date	Value
2019: CAPITOL HOME HEALTH - HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-10-01	119
Total number of active participants reported on line 7a of the Form 5500	2019-10-01	92
Number of retired or separated participants receiving benefits	2019-10-01	5
Number of other retired or separated participants entitled to future benefits	2019-10-01	44
Total of all active and inactive participants	2019-10-01	141
Number of employers contributing to the scheme	2019-10-01	0

Form 5500 Responses for CAPITOL HOME HEALTH - HEALTH AND WELFARE PLAN

2019: CAPITOL HOME HEALTH - HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-10-01	Type of plan entity	Single employer plan
2019-10-01	First time form 5500 has been submitted	Yes
2019-10-01	Submission has been amended	Yes
2019-10-01	Plan funding arrangement – Insurance	Yes
2019-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

829714

Policy instance

Insurance contract or identification number	829714
Number of Individuals Covered	60
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $4,779
Total amount of fees paid to insurance company	USD $2,266
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,779
Amount paid for insurance broker fees	2266
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 )

Policy contract number

829714

Policy instance

Insurance contract or identification number	829714
Number of Individuals Covered	13
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $481
Total amount of fees paid to insurance company	USD $675
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $481
Amount paid for insurance broker fees	675
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

HUMANA HEALTH PLAN OF TEXAS, INC. (National Association of Insurance Commissioners NAIC id number: 95024 )

Policy contract number

829714

Policy instance

Insurance contract or identification number	829714
Number of Individuals Covered	67
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $35,311
Total amount of fees paid to insurance company	USD $2,379
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $800,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,311
Amount paid for insurance broker fees	2379
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BLGB

Policy instance

Insurance contract or identification number	GLUG0BLGB
Number of Individuals Covered	82
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $6,143
Total amount of fees paid to insurance company	USD $1,201
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $61,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,143
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OTHER COMPENSATION

Potentially related plans

CAPITOL HOME HEALTH INC 401(K) PROFIT SHARING PLAN AND TRUST [EIN = 383978250]

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Company Name:	CAPITOL HOME HEALTH
Employer identification number (EIN):	272266477
NAIC Classification:	621610
NAIC Description:	Home Health Care Services