401k Plan data: COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN plan

COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN
Plan identification number	501

COLD SPRING HOLDINGS LLC 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) Other welfare benefit cover

401k Sponsoring company profile

COLD SPRING HOLDINGS, LLC has sponsored the creation of one or more 401k plans.

Company Name: COLD SPRING HOLDINGS, LLC

Employer identification number (EIN): 275550949

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

Additional information about COLD SPRING HOLDINGS, LLC

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2011-03-11

Company Identification Number: 0801396624

Legal Registered Office Address: PO BOX 2057

DENTON
United States of America (USA)
76202

More information about COLD SPRING HOLDINGS, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-01-01
501 2014-01-01 BARBARA ANDERSON BARBARA ANDERSON 2015-06-25

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2015-01-01
501	2014-01-01	BARBARA ANDERSON		BARBARA ANDERSON	2015-06-25

Plan Statistics for COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN

Measure Date Value
2015: COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 219
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 164
Total of all active and inactive participants 2015-01-01 164
2014: COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 219
Total of all active and inactive participants 2014-01-01 219

Measure	Date	Value
2015: COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	219
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	164
Total of all active and inactive participants	2015-01-01	164
2014: COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	219
Total of all active and inactive participants	2014-01-01	219

Form 5500 Responses for COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN

2015: COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: COLD SPRING HOLDINGS LLC HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	First time form 5500 has been submitted	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

68904-1

Policy instance

Insurance contract or identification number	68904-1
Number of Individuals Covered	172
Insurance policy start date	2015-07-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,837
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACC/AD&D/CI/HCI/VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $19,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,837
Insurance broker organization code?	3
Insurance broker name	RYAN BENEFITS, INC.

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

Policy contract number

GVTL0AR89

Policy instance

Insurance contract or identification number	GVTL0AR89
Number of Individuals Covered	20
Insurance policy start date	2015-01-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $325
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $325
Insurance broker organization code?	3
Insurance broker name	RYAN BENEFITS, INC.

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

Policy contract number

GLUG0AR89

Policy instance

Insurance contract or identification number	GLUG0AR89
Number of Individuals Covered	168
Insurance policy start date	2015-01-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $455
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $455
Insurance broker organization code?	3
Insurance broker name	RYAN BENEFITS, INC.

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-040242

Policy instance

Insurance contract or identification number	010-040242
Number of Individuals Covered	210
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,067
Total amount of fees paid to insurance company	USD $158
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,067
Amount paid for insurance broker fees	158
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	RYAN BENEFITS, INC.

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

CHC5158

Policy instance

Insurance contract or identification number	CHC5158
Number of Individuals Covered	47
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,144
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,144
Insurance broker organization code?	3
Insurance broker name	RYAN BENEFITS, INC.

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

E8W67

Policy instance

Insurance contract or identification number	E8W67
Number of Individuals Covered	70
Insurance policy start date	2015-01-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $11,071
Total amount of fees paid to insurance company	USD $589
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT/CANCER,HEART/STROKE
Welfare Benefit Premiums Paid to Carrier	USD $39,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,559
Amount paid for insurance broker fees	247
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	JULIE A HAUK

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

Policy contract number

GVTL0AR89

Policy instance

Insurance contract or identification number	GVTL0AR89
Number of Individuals Covered	16
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $610
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $610
Insurance broker organization code?	3
Insurance broker name	RYAN BENEFITS, INC.

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

Policy contract number

GLUG0AR89

Policy instance

Insurance contract or identification number	GLUG0AR89
Number of Individuals Covered	148
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $833
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $833
Insurance broker organization code?	3
Insurance broker name	RYAN BENEFITS, INC.

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-040242

Policy instance

Insurance contract or identification number	010-040242
Number of Individuals Covered	120
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,130
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,130
Insurance broker organization code?	3
Insurance broker name	RYAN BENEFITS, INC.

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

LFIBP-CHC5158

Policy instance

Insurance contract or identification number	LFIBP-CHC5158
Number of Individuals Covered	14
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,157
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,157
Insurance broker organization code?	3
Insurance broker name	RYAN BENEFITS, INC.

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

E8W67

Policy instance

Insurance contract or identification number	E8W67
Number of Individuals Covered	76
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $25,678
Total amount of fees paid to insurance company	USD $1,015
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT/CANCER,HEART/STROKE
Welfare Benefit Premiums Paid to Carrier	USD $75,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,833
Amount paid for insurance broker fees	358
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	JULIE A HAUK

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Company Name:	COLD SPRING HOLDINGS, LLC
Employer identification number (EIN):	275550949
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2011-03-11
Company Identification Number:	0801396624
Legal Registered Office Address:	PO BOX 2057 DENTON United States of America (USA) 76202