401k Plan data: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN plan

PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN
Plan identification number	502

PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS 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

PREMIER SNF SERVICES LLC has sponsored the creation of one or more 401k plans.

Company Name: PREMIER SNF SERVICES LLC

Employer identification number (EIN): 453744352

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

Additional information about PREMIER SNF SERVICES LLC

Jurisdiction of Incorporation: Ohio Secretary of State Business Services Division

Incorporation Date: 2011-10-25

Company Identification Number: 2057135

Legal Registered Office Address: 1301 E NINTH ST STE 3500
-
CLEVELAND
United States of America (USA)
44114

More information about PREMIER SNF SERVICES LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2016-01-01 JOSEPH VINCE JOSEPH VINCE 2016-08-30
502 2015-01-01 JOSEPH VINCE JOSEPH VINCE 2016-08-30
502 2014-01-01 JOSEPH J VINCE
502 2013-01-01 JOSEPH VINCE JOSEPH VINCE 2014-09-16

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
502	2016-01-01	JOSEPH VINCE	JOSEPH VINCE	2016-08-30
502	2015-01-01	JOSEPH VINCE	JOSEPH VINCE	2016-08-30
502	2014-01-01	JOSEPH J VINCE
502	2013-01-01	JOSEPH VINCE	JOSEPH VINCE	2014-09-16

Plan Statistics for PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN

Measure Date Value
2016: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 121
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
2015: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 121
Total of all active and inactive participants 2015-01-01 121
2014: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 248
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 110
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 110
2013: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 248
Total of all active and inactive participants 2013-01-01 248

Measure	Date	Value
2016: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
2015: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	121
Total of all active and inactive participants	2015-01-01	121
2014: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	248
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	110
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	110
2013: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	248
Total of all active and inactive participants	2013-01-01	248

Form 5500 Responses for PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN

2016: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	This submission is the final filing	Yes
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS 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 funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: PREMIER SNF SERVICES, LLC EMPLOYEE BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	First time form 5500 has been submitted	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

Policy instance

Number of Individuals Covered	0
Insurance policy start date	2016-02-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,241
Other welfare benefits provided	CLAIMS ADMINISTRATION
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1241
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	5
Insurance broker name

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0849512

Policy instance

Insurance contract or identification number	0849512
Number of Individuals Covered	131
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $654
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $5,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $654
Insurance broker name	MCCAMON HUNT INSURANCE AGENCY

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 96518 )

Policy contract number

0849512HNO

Policy instance

Insurance contract or identification number	0849512HNO
Number of Individuals Covered	151
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $882,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

Policy instance

Number of Individuals Covered	103
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,858
Other welfare benefits provided	CLAIMS ADMINISTRATION
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3858
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	5
Insurance broker name

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00188582

Policy instance

Insurance contract or identification number	00188582
Number of Individuals Covered	45
Insurance policy start date	2015-08-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $9,500
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $348,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,500
Insurance broker name	MCCAMON HUNT INSURANCE AGENCY

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

Policy contract number

RY930

Policy instance

Insurance contract or identification number	RY930
Number of Individuals Covered	3
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $242
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	ACCIDENT, HOSPITAL, CANCER, CRITICAL ILLNESS, DENTAL, VISION
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 $1,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $94
Insurance broker organization code?	3
Insurance broker name	MARILYN WYMAN

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

Policy contract number

TH056

Policy instance

Insurance contract or identification number	TH056
Number of Individuals Covered	41
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,932
Total amount of fees paid to insurance company	USD $34
Are there contracts with allocated funds for individual policies?	No
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	ACCIDENT, HOSPITAL, CANCER, CRITICAL ILLNESS, DENTAL, VISION
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 $19,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,510
Insurance broker organization code?	3
Amount paid for insurance broker fees	22
Additional information about fees paid to insurance broker	FEES
Insurance broker name	DAVID P AESOPH

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

Policy contract number

D9X38

Policy instance

Insurance contract or identification number	D9X38
Number of Individuals Covered	22
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,105
Total amount of fees paid to insurance company	USD $168
Are there contracts with allocated funds for individual policies?	No
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	ACCIDENT, HOSPITAL, CANCER, CRITICAL ILLNESS, DENTAL, VISION
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 $8,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $689
Amount paid for insurance broker fees	57
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	DAVID P AESOPH

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

Policy contract number

DBV30

Policy instance

Insurance contract or identification number	DBV30
Number of Individuals Covered	43
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,243
Total amount of fees paid to insurance company	USD $22
Are there contracts with allocated funds for individual policies?	No
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	ACCIDENT, HOSPITAL, CRITICAL ILLNESS, CANCER, DENTAL, VISION
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 $27,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $924
Insurance broker organization code?	3
Amount paid for insurance broker fees	13
Additional information about fees paid to insurance broker	FEES
Insurance broker name	RANDY R PETRELLA

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

Policy contract number

DPX35

Policy instance

Insurance contract or identification number	DPX35
Number of Individuals Covered	0
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $35
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	ACCIDENT, HOSPITAL, CANCER, CRITICAL ILLNESS, DENTAL, VISION
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 $337
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13
Insurance broker organization code?	3
Insurance broker name	MARIO HAIFA

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

Policy contract number

HM334

Policy instance

Insurance contract or identification number	HM334
Number of Individuals Covered	11
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $945
Total amount of fees paid to insurance company	USD $47
Are there contracts with allocated funds for individual policies?	No
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	ACCIDENT, HOSPITAL, CANCER, CRITICAL ILLNESS, DENTAL, VISION
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 $5,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $322
Amount paid for insurance broker fees	29
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	QUINN, MEYER & ASSOCIATES

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

Policy contract number

F6H43

Policy instance

Insurance contract or identification number	F6H43
Number of Individuals Covered	5
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $154
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	ACCIDENT, HOSPITAL, CANCER, CRITICAL ILLNESS, DENTAL, VISION
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 $1,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42
Insurance broker organization code?	3
Insurance broker name	MARIO HAIFA

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00172320

Policy instance

Insurance contract or identification number	00172320
Number of Individuals Covered	0
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $425
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
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 $5,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $425
Insurance broker organization code?	3
Insurance broker name	MCCAMON HUNT INS AGENCY INC

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00172320

Policy instance

Insurance contract or identification number	00172320
Number of Individuals Covered	110
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $24,440
Total amount of fees paid to insurance company	USD $1,620
Are there contracts with allocated funds for individual policies?	No
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 $700,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,440
Amount paid for insurance broker fees	1620
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	MCCAMON HUNT INS AGENCY INC

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00172320

Policy instance

Insurance contract or identification number	00172320
Number of Individuals Covered	0
Insurance policy start date	2013-08-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $218
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
Welfare Benefit Premiums Paid to Carrier	USD $2,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $218
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MCCAMON HUNT INSURANCE AGENCY

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

Policy contract number

58-0663085

Policy instance

Insurance contract or identification number	58-0663085
Number of Individuals Covered	15
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,304
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $805
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MICHAEL QUINN

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

Policy contract number

58-0663085

Policy instance

Insurance contract or identification number	58-0663085
Number of Individuals Covered	3
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $294
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $229
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARIO HAIFA

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

Policy contract number

58-0663085

Policy instance

Insurance contract or identification number	58-0663085
Number of Individuals Covered	48
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,570
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,838
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	TINA MILNER

AFLAC D9X38 (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

58-0663085

Policy instance

Insurance contract or identification number	58-0663085
Number of Individuals Covered	27
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,517
Total amount of fees paid to insurance company	USD $95
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,672
Amount paid for insurance broker fees	59
Additional information about fees paid to insurance broker	BONUSES AND INCENTIVES
Insurance broker organization code?	3
Insurance broker name	TIMOTHY QUINLAN

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

Policy contract number

58-0663085

Policy instance

Insurance contract or identification number	58-0663085
Number of Individuals Covered	46
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,056
Total amount of fees paid to insurance company	USD $14
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,053
Amount paid for insurance broker fees	8
Additional information about fees paid to insurance broker	BONUSES AND INCENTIVES
Insurance broker organization code?	3
Insurance broker name	RANDY PETRELLA

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

Policy contract number

58-0663085

Policy instance

Insurance contract or identification number	58-0663085
Number of Individuals Covered	2
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $205
Total amount of fees paid to insurance company	USD $30
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $132
Amount paid for insurance broker fees	18
Additional information about fees paid to insurance broker	BONUSES AND INCENTIVES
Insurance broker organization code?	3
Insurance broker name	BILLY CRAIN

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

Policy contract number

58-0663085

Policy instance

Insurance contract or identification number	58-0663085
Number of Individuals Covered	1
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $74
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARIO HAIFA

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00172320

Policy instance

Insurance contract or identification number	00172320
Number of Individuals Covered	106
Insurance policy start date	2013-08-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
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 $284,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	PREMIER SNF SERVICES LLC
Employer identification number (EIN):	453744352
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Ohio Secretary of State Business Services Division
Incorporation Date:	2011-10-25
Company Identification Number:	2057135
Legal Registered Office Address:	1301 E NINTH ST STE 3500 - CLEVELAND United States of America (USA) 44114