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| Plan Name | VILLAS MEDICAL PLAN |
| Plan identification number | 502 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | LILIHA KUPUNA SNF, LLC |
| Employer identification number (EIN): | 465740605 |
| NAIC Classification: | 623000 |
| NAIC Description: | Nursing and Residential Care Facilities |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 502 | 2021-01-01 | ||||
| 502 | 2020-01-01 |
| Measure | Date | Value |
|---|---|---|
| 2021: VILLAS MEDICAL PLAN 2021 401k membership | ||
| Total participants, beginning-of-year | 2021-01-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 96 |
| Total of all active and inactive participants | 2021-01-01 | 96 |
| Total participants | 2021-01-01 | 96 |
| 2020: VILLAS MEDICAL PLAN 2020 401k membership | ||
| Total participants, beginning-of-year | 2020-01-01 | 96 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 114 |
| Total of all active and inactive participants | 2020-01-01 | 114 |
| Total participants | 2020-01-01 | 114 |
| 2021: VILLAS MEDICAL PLAN 2021 form 5500 responses | ||
|---|---|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: VILLAS MEDICAL PLAN 2020 form 5500 responses | ||
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | First time form 5500 has been submitted | Yes |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 ) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | |||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||
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| HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 ) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 56344 | ||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||
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