401k Plan data: ANGELS PLACE WELFARE BENEFIT PLAN plan

ANGELS PLACE WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	ANGELS PLACE WELFARE BENEFIT PLAN
Plan identification number	501

ANGELS PLACE WELFARE BENEFIT 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

401k Sponsoring company profile

ANGELS' PLACE has sponsored the creation of one or more 401k plans.

Company Name: ANGELS' PLACE

Employer identification number (EIN): 383068201

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ANGELS PLACE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-10-01 THOMAS SZCZEPANSKI 2024-03-02

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-10-01	THOMAS SZCZEPANSKI	2024-03-02

Plan Statistics for ANGELS PLACE WELFARE BENEFIT PLAN

401k plan membership statisitcs for ANGELS PLACE WELFARE BENEFIT PLAN

Measure Date Value
2022: ANGELS PLACE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-10-01 122
Total number of active participants reported on line 7a of the Form 5500 2022-10-01 135
Number of retired or separated participants receiving benefits 2022-10-01 0
Number of other retired or separated participants entitled to future benefits 2022-10-01 2
Total of all active and inactive participants 2022-10-01 137

Measure	Date	Value
2022: ANGELS PLACE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-10-01	122
Total number of active participants reported on line 7a of the Form 5500	2022-10-01	135
Number of retired or separated participants receiving benefits	2022-10-01	0
Number of other retired or separated participants entitled to future benefits	2022-10-01	2
Total of all active and inactive participants	2022-10-01	137

Form 5500 Responses for ANGELS PLACE WELFARE BENEFIT PLAN

2022: ANGELS PLACE WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-10-01	Type of plan entity	Single employer plan
2022-10-01	First time form 5500 has been submitted	Yes
2022-10-01	Submission has been amended	No
2022-10-01	This submission is the final filing	No
2022-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-10-01	Plan is a collectively bargained plan	No
2022-10-01	Plan funding arrangement – Insurance	Yes
2022-10-01	Plan funding arrangement – Section 412(e)(3) insurance Contracts	Yes
2022-10-01	Plan benefit arrangement – Insurance	Yes
2022-10-01	Plan benefit arrangement – Section 412(e)(3) insurance Contracts	Yes

Insurance Providers Used on plan

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10005653

Policy instance

Insurance contract or identification number	10005653
Number of Individuals Covered	84
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $31,511
Total amount of fees paid to insurance company	USD $0
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 $551,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,031
Insurance broker organization code?	3

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

Policy contract number

G000BRT2

Policy instance

Insurance contract or identification number	G000BRT2
Number of Individuals Covered	135
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $10,035
Total amount of fees paid to insurance company	USD $6,684
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	Yes
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	AD&D, VOLUNTARY LIFE AND ACCIDENTAL DEATH
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 $99,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,035
Amount paid for insurance broker fees	4823
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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Company Name:	ANGELS' PLACE
Employer identification number (EIN):	383068201
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities