401k Plan data: SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN plan

SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN 401k Plan overview

Plan Name	SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN
Plan identification number	502

SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Vision 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

SHADOWS BEND COURT, L.L.C. has sponsored the creation of one or more 401k plans.

Company Name: SHADOWS BEND COURT, L.L.C.

Employer identification number (EIN): 364435957

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2021-04-01 DAVID SCHONBERG 2022-10-05
502 2020-04-01 MICHAEL SCHONBERG 2021-10-20
502 2019-04-01 MICHAEL SCHONBERG 2020-10-07

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
502	2021-04-01	DAVID SCHONBERG	2022-10-05
502	2020-04-01	MICHAEL SCHONBERG	2021-10-20
502	2019-04-01	MICHAEL SCHONBERG	2020-10-07

Plan Statistics for SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN

401k plan membership statisitcs for SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN

Measure Date Value
2021: SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN 2021 401k membership
Total participants, beginning-of-year 2021-04-01 308
Total number of active participants reported on line 7a of the Form 5500 2021-04-01 39
Number of retired or separated participants receiving benefits 2021-04-01 0
Number of other retired or separated participants entitled to future benefits 2021-04-01 1
Total of all active and inactive participants 2021-04-01 40
2020: SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN 2020 401k membership
Total participants, beginning-of-year 2020-04-01 227
Total number of active participants reported on line 7a of the Form 5500 2020-04-01 296
Number of retired or separated participants receiving benefits 2020-04-01 3
Number of other retired or separated participants entitled to future benefits 2020-04-01 9
Total of all active and inactive participants 2020-04-01 308
2019: SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN 2019 401k membership
Total participants, beginning-of-year 2019-04-01 200
Total number of active participants reported on line 7a of the Form 5500 2019-04-01 191
Number of retired or separated participants receiving benefits 2019-04-01 3
Number of other retired or separated participants entitled to future benefits 2019-04-01 33
Total of all active and inactive participants 2019-04-01 227

Measure	Date	Value
2021: SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN 2021 401k membership
Total participants, beginning-of-year	2021-04-01	308
Total number of active participants reported on line 7a of the Form 5500	2021-04-01	39
Number of retired or separated participants receiving benefits	2021-04-01	0
Number of other retired or separated participants entitled to future benefits	2021-04-01	1
Total of all active and inactive participants	2021-04-01	40
2020: SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN 2020 401k membership
Total participants, beginning-of-year	2020-04-01	227
Total number of active participants reported on line 7a of the Form 5500	2020-04-01	296
Number of retired or separated participants receiving benefits	2020-04-01	3
Number of other retired or separated participants entitled to future benefits	2020-04-01	9
Total of all active and inactive participants	2020-04-01	308
2019: SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN 2019 401k membership
Total participants, beginning-of-year	2019-04-01	200
Total number of active participants reported on line 7a of the Form 5500	2019-04-01	191
Number of retired or separated participants receiving benefits	2019-04-01	3
Number of other retired or separated participants entitled to future benefits	2019-04-01	33
Total of all active and inactive participants	2019-04-01	227

Form 5500 Responses for SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN

2021: SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN 2021 form 5500 responses
2021-04-01	Type of plan entity	Single employer plan
2021-04-01	Submission has been amended	No
2021-04-01	This submission is the final filing	No
2021-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-04-01	Plan is a collectively bargained plan	No
2021-04-01	Plan funding arrangement – Insurance	Yes
2021-04-01	Plan benefit arrangement – Insurance	Yes
2020: SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN 2020 form 5500 responses
2020-04-01	Type of plan entity	Single employer plan
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
2019: SHADOWS BEND COURT, L.L.C. DBA THE SUITES AT SUGAR MILL VISION PLAN 2019 form 5500 responses
2019-04-01	Type of plan entity	Single employer plan
2019-04-01	First time form 5500 has been submitted	Yes
2019-04-01	Submission has been amended	No
2019-04-01	This submission is the final filing	No
2019-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-04-01	Plan is a collectively bargained plan	No
2019-04-01	Plan funding arrangement – Insurance	Yes
2019-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF LOUISIANA (National Association of Insurance Commissioners NAIC id number: 81200 )

Policy contract number

78N09ERC

Policy instance

Insurance contract or identification number	78N09ERC
Number of Individuals Covered	72
Insurance policy start date	2021-04-01
Insurance policy end date	2022-03-31
Total amount of commissions paid to insurance broker	USD $1,413
Total amount of fees paid to insurance company	USD $333
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
Welfare Benefit Premiums Paid to Carrier	USD $14,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,413
Amount paid for insurance broker fees	333
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF LOUISIANA (National Association of Insurance Commissioners NAIC id number: 81200 )

Policy contract number

78N09ERC

Policy instance

Insurance contract or identification number	78N09ERC
Number of Individuals Covered	173
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $12,741
Total amount of fees paid to insurance company	USD $2,063
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
Welfare Benefit Premiums Paid to Carrier	USD $19,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $12,741
Amount paid for insurance broker fees	2063
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF LOUISIANA (National Association of Insurance Commissioners NAIC id number: 81200 )

Policy contract number

78N09ERC

Policy instance

Insurance contract or identification number	78N09ERC
Number of Individuals Covered	276
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $12,005
Total amount of fees paid to insurance company	USD $806
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
Welfare Benefit Premiums Paid to Carrier	USD $22,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $12,005
Amount paid for insurance broker fees	806
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

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Company Name:	SHADOWS BEND COURT, L.L.C.
Employer identification number (EIN):	364435957
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities