401k Plan data: TABITHA, INC. HEALTH AND WELFARE PLAN plan

TABITHA, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	TABITHA, INC. HEALTH AND WELFARE PLAN
Plan identification number	515

TABITHA, INC. 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) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

TABITHA, INC. has sponsored the creation of one or more 401k plans.

Company Name: TABITHA, INC.

Employer identification number (EIN): 470377998

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TABITHA, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
515 2022-01-01
515 2021-01-01
515 2020-01-01
515 2019-01-01
515 2018-09-01 TAMI OCKEN
515 2017-09-01
515 2016-09-01 TAMI OCKEN

Plan Statistics for TABITHA, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for TABITHA, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2022: TABITHA, INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 527
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 528
Number of retired or separated participants receiving benefits 2022-01-01 3
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 531
2021: TABITHA, INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 553
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 523
Number of retired or separated participants receiving benefits 2021-01-01 4
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 527
2020: TABITHA, INC. HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 597
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 547
Number of retired or separated participants receiving benefits 2020-01-01 6
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 553
2019: TABITHA, INC. HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 580
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 594
Number of retired or separated participants receiving benefits 2019-01-01 3
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 597
2018: TABITHA, INC. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-09-01 930
Total number of active participants reported on line 7a of the Form 5500 2018-09-01 925
Number of retired or separated participants receiving benefits 2018-09-01 7
Number of other retired or separated participants entitled to future benefits 2018-09-01 0
Total of all active and inactive participants 2018-09-01 932
2017: TABITHA, INC. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-09-01 937
Total number of active participants reported on line 7a of the Form 5500 2017-09-01 925
Number of retired or separated participants receiving benefits 2017-09-01 5
Number of other retired or separated participants entitled to future benefits 2017-09-01 0
Total of all active and inactive participants 2017-09-01 930
2016: TABITHA, INC. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-09-01 607
Total number of active participants reported on line 7a of the Form 5500 2016-09-01 930
Number of retired or separated participants receiving benefits 2016-09-01 7
Number of other retired or separated participants entitled to future benefits 2016-09-01 0
Total of all active and inactive participants 2016-09-01 937

Measure	Date	Value
2022: TABITHA, INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	527
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	528
Number of retired or separated participants receiving benefits	2022-01-01	3
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	531
2021: TABITHA, INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	553
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	523
Number of retired or separated participants receiving benefits	2021-01-01	4
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	527
2020: TABITHA, INC. HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	597
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	547
Number of retired or separated participants receiving benefits	2020-01-01	6
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	553
2019: TABITHA, INC. HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	580
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	594
Number of retired or separated participants receiving benefits	2019-01-01	3
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	597
2018: TABITHA, INC. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-09-01	930
Total number of active participants reported on line 7a of the Form 5500	2018-09-01	925
Number of retired or separated participants receiving benefits	2018-09-01	7
Number of other retired or separated participants entitled to future benefits	2018-09-01	0
Total of all active and inactive participants	2018-09-01	932
2017: TABITHA, INC. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-09-01	937
Total number of active participants reported on line 7a of the Form 5500	2017-09-01	925
Number of retired or separated participants receiving benefits	2017-09-01	5
Number of other retired or separated participants entitled to future benefits	2017-09-01	0
Total of all active and inactive participants	2017-09-01	930
2016: TABITHA, INC. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-09-01	607
Total number of active participants reported on line 7a of the Form 5500	2016-09-01	930
Number of retired or separated participants receiving benefits	2016-09-01	7
Number of other retired or separated participants entitled to future benefits	2016-09-01	0
Total of all active and inactive participants	2016-09-01	937

Form 5500 Responses for TABITHA, INC. HEALTH AND WELFARE PLAN

2022: TABITHA, INC. HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: TABITHA, INC. HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
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: TABITHA, INC. HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
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
2019: TABITHA, INC. HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: TABITHA, INC. HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-09-01	Type of plan entity	Single employer plan
2018-09-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2018-09-01	Plan funding arrangement – Insurance	Yes
2018-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-09-01	Plan benefit arrangement – Insurance	Yes
2018-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: TABITHA, INC. HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-09-01	Type of plan entity	Single employer plan
2017-09-01	Plan funding arrangement – Insurance	Yes
2017-09-01	Plan benefit arrangement – Insurance	Yes
2016: TABITHA, INC. HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-09-01	Type of plan entity	Single employer plan
2016-09-01	First time form 5500 has been submitted	Yes
2016-09-01	Plan funding arrangement – Insurance	Yes
2016-09-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

1000534

Policy instance

Insurance contract or identification number	1000534
Number of Individuals Covered	333
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,772
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $37,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,772
Insurance broker organization code?	3

DIRECTIONS EAP, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	852
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $17,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

010-057991

Policy instance

Insurance contract or identification number	010-057991
Number of Individuals Covered	662
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,914
Total amount of fees paid to insurance company	USD $784
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,552
Insurance broker organization code?	3
Amount paid for insurance broker fees	784
Additional information about fees paid to insurance broker	FEES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010130902

Policy instance

Insurance contract or identification number	000010130902
Number of Individuals Covered	47
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,768
Total amount of fees paid to insurance company	USD $113
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,768
Insurance broker organization code?	3
Amount paid for insurance broker fees	113
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010194272

Policy instance

Insurance contract or identification number	000010194272
Number of Individuals Covered	151
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,459
Total amount of fees paid to insurance company	USD $604
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $82,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,459
Insurance broker organization code?	3
Amount paid for insurance broker fees	604
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010094417

Policy instance

Insurance contract or identification number	000010094417
Number of Individuals Covered	528
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $10,599
Total amount of fees paid to insurance company	USD $458
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $70,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,599
Insurance broker organization code?	3
Amount paid for insurance broker fees	458
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100007054

Policy instance

Insurance contract or identification number	40000100007054
Number of Individuals Covered	446
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $13,288
Total amount of fees paid to insurance company	USD $558
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $88,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,288
Insurance broker organization code?	3
Amount paid for insurance broker fees	558
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010194273

Policy instance

Insurance contract or identification number	000010194273
Number of Individuals Covered	528
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,639
Total amount of fees paid to insurance company	USD $1,166
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $179,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,639
Insurance broker organization code?	3
Amount paid for insurance broker fees	1166
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010194273

Policy instance

Insurance contract or identification number	000010194273
Number of Individuals Covered	526
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,942
Total amount of fees paid to insurance company	USD $2,131
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $155,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,942
Insurance broker organization code?	3
Amount paid for insurance broker fees	2131
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100007054

Policy instance

Insurance contract or identification number	40000100007054
Number of Individuals Covered	435
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $11,154
Total amount of fees paid to insurance company	USD $914
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $74,361
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,154
Insurance broker organization code?	3
Amount paid for insurance broker fees	914
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010094417

Policy instance

Insurance contract or identification number	000010094417
Number of Individuals Covered	523
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,154
Total amount of fees paid to insurance company	USD $859
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $61,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,154
Insurance broker organization code?	3
Amount paid for insurance broker fees	859
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010130902

Policy instance

Insurance contract or identification number	000010130902
Number of Individuals Covered	39
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,114
Total amount of fees paid to insurance company	USD $215
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,114
Amount paid for insurance broker fees	215
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

1000534

Policy instance

Insurance contract or identification number	1000534
Number of Individuals Covered	325
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,005
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $40,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,005
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

519365

Policy instance

Insurance contract or identification number	519365
Number of Individuals Covered	4
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $148
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $2,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $148
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30068340

Policy instance

Insurance contract or identification number	30068340
Number of Individuals Covered	276
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $8,799
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,799
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010194272

Policy instance

Insurance contract or identification number	000010194272
Number of Individuals Covered	151
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,963
Total amount of fees paid to insurance company	USD $1,077
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $80,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,963
Insurance broker organization code?	3
Amount paid for insurance broker fees	1077
Additional information about fees paid to insurance broker	BROKER BONUS

DIRECTIONS EAP, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	890
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $12,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10094417

Policy instance

Insurance contract or identification number	10094417
Number of Individuals Covered	594
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $10,314
Total amount of fees paid to insurance company	USD $3,004
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $68,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,314
Amount paid for insurance broker fees	3004
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

DIRECTIONS EAP, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	999
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $12,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10130902

Policy instance

Insurance contract or identification number	10130902
Number of Individuals Covered	39
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,460
Total amount of fees paid to insurance company	USD $508
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,460
Amount paid for insurance broker fees	508
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30068340

Policy instance

Insurance contract or identification number	30068340
Number of Individuals Covered	318
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,687
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,687
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

519365

Policy instance

Insurance contract or identification number	519365
Number of Individuals Covered	4
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,819
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $17,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,819
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10194272

Policy instance

Insurance contract or identification number	10194272
Number of Individuals Covered	160
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,857
Total amount of fees paid to insurance company	USD $2,695
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $86,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,857
Amount paid for insurance broker fees	2695
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

1000534

Policy instance

Insurance contract or identification number	1000534
Number of Individuals Covered	830
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,287
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $42,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,287
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100007054

Policy instance

Insurance contract or identification number	40000100007054
Number of Individuals Covered	427
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $10,971
Total amount of fees paid to insurance company	USD $1,903
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $73,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,971
Amount paid for insurance broker fees	1903
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10194273

Policy instance

Insurance contract or identification number	10194273
Number of Individuals Covered	547
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,297
Total amount of fees paid to insurance company	USD $5,392
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $170,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,297
Amount paid for insurance broker fees	5392
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

1000534

Policy instance

Insurance contract or identification number	1000534
Number of Individuals Covered	853
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,337
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $43,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,337
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10194273

Policy instance

Insurance contract or identification number	10194273
Number of Individuals Covered	550
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,146
Total amount of fees paid to insurance company	USD $-1,703
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $154,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,146
Insurance broker organization code?	3
Amount paid for insurance broker fees	-1703
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100007054

Policy instance

Insurance contract or identification number	40000100007054
Number of Individuals Covered	367
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $8,156
Total amount of fees paid to insurance company	USD $-626
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $54,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,156
Insurance broker organization code?	3
Amount paid for insurance broker fees	-626
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10094417

Policy instance

Insurance contract or identification number	10094417
Number of Individuals Covered	641
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $12,874
Total amount of fees paid to insurance company	USD $-955
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $85,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,874
Insurance broker organization code?	3
Amount paid for insurance broker fees	-955
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10194272

Policy instance

Insurance contract or identification number	10194272
Number of Individuals Covered	167
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,351
Total amount of fees paid to insurance company	USD $-873
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,351
Insurance broker organization code?	3
Amount paid for insurance broker fees	-873
Additional information about fees paid to insurance broker	BROKER BONUS

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30068340

Policy instance

Insurance contract or identification number	30068340
Number of Individuals Covered	320
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,754
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,754
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10130902

Policy instance

Insurance contract or identification number	10130902
Number of Individuals Covered	42
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,052
Total amount of fees paid to insurance company	USD $-218
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,052
Insurance broker organization code?	3
Amount paid for insurance broker fees	-218
Additional information about fees paid to insurance broker	BROKER BONUS

DIRECTIONS EAP, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	925
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $12,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

519365

Policy instance

Insurance contract or identification number	519365
Number of Individuals Covered	15
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,682
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $17,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,682
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010130902

Policy instance

Insurance contract or identification number	000010130902
Number of Individuals Covered	40
Insurance policy start date	2018-09-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,129
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,129
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30068340

Policy instance

Insurance contract or identification number	30068340
Number of Individuals Covered	303
Insurance policy start date	2018-09-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,550
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,550
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

519365

Policy instance

Insurance contract or identification number	519365
Number of Individuals Covered	7
Insurance policy start date	2018-09-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $535
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $4,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $535
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010194272

Policy instance

Insurance contract or identification number	000010194272
Number of Individuals Covered	159
Insurance policy start date	2018-09-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,399
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,399
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010094417

Policy instance

Insurance contract or identification number	000010094417
Number of Individuals Covered	627
Insurance policy start date	2018-09-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,256
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $35,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,256
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010194273

Policy instance

Insurance contract or identification number	000010194273
Number of Individuals Covered	550
Insurance policy start date	2018-09-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,965
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,965
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

1000534

Policy instance

Insurance contract or identification number	1000534
Number of Individuals Covered	356
Insurance policy start date	2018-09-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,356
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $13,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,356
Insurance broker organization code?	3

DIRECTIONS EAP, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	925
Insurance policy start date	2018-09-01
Insurance policy end date	2018-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $4,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100007054

Policy instance

Insurance contract or identification number	40000100007054
Number of Individuals Covered	370
Insurance policy start date	2018-09-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,831
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $25,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,831
Insurance broker organization code?	3

DIRECTIONS EAP, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	925
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $11,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100007054

Policy instance

Insurance contract or identification number	40000100007054
Number of Individuals Covered	367
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $10,469
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $54,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010194273

Policy instance

Insurance contract or identification number	000010194273
Number of Individuals Covered	532
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $6,659
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010094417

Policy instance

Insurance contract or identification number	000010094417
Number of Individuals Covered	600
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $10,811
Total amount of fees paid to insurance company	USD $170
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $72,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010194272

Policy instance

Insurance contract or identification number	000010194272
Number of Individuals Covered	159
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $7,563
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

1000534

Policy instance

Insurance contract or identification number	1000534
Number of Individuals Covered	809
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $4,073
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	MANAGED ORGAN/TISSUE TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $40,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

519365

Policy instance

Insurance contract or identification number	519365
Number of Individuals Covered	2
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $2,365
Other welfare benefits provided	GROUP LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $15,767
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010130902

Policy instance

Insurance contract or identification number	000010130902
Number of Individuals Covered	42
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $3,500
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30068340

Policy instance

Insurance contract or identification number	30068340
Number of Individuals Covered	295
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $8,070
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	TABITHA, INC.
Employer identification number (EIN):	470377998
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities