401k Plan data: OMEGA SENIOR LIVING, LLC plan

OMEGA SENIOR LIVING, LLC 401k Plan overview

Plan Name	OMEGA SENIOR LIVING, LLC
Plan identification number	502

OMEGA SENIOR LIVING, LLC Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Temporary disability (accident and sickness) Other welfare benefit cover

401k Sponsoring company profile

OMEGA SENIOR LIVING, LLC has sponsored the creation of one or more 401k plans.

Company Name: OMEGA SENIOR LIVING, LLC

Employer identification number (EIN): 811853612

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OMEGA SENIOR LIVING, LLC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2017-05-01 LORI PROTHRO
502 2016-05-01 CRAIG HANSON CRAIG HANSON 2017-12-18

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2017-05-01	LORI PROTHRO
502	2016-05-01	CRAIG HANSON		CRAIG HANSON	2017-12-18

Plan Statistics for OMEGA SENIOR LIVING, LLC

401k plan membership statisitcs for OMEGA SENIOR LIVING, LLC

Measure Date Value
2017: OMEGA SENIOR LIVING, LLC 2017 401k membership
Total participants, beginning-of-year 2017-05-01 264
Total number of active participants reported on line 7a of the Form 5500 2017-05-01 0
Number of retired or separated participants receiving benefits 2017-05-01 0
Number of other retired or separated participants entitled to future benefits 2017-05-01 0
Total of all active and inactive participants 2017-05-01 0
2016: OMEGA SENIOR LIVING, LLC 2016 401k membership
Total participants, beginning-of-year 2016-05-01 201
Total number of active participants reported on line 7a of the Form 5500 2016-05-01 264
Total of all active and inactive participants 2016-05-01 264

Measure	Date	Value
2017: OMEGA SENIOR LIVING, LLC 2017 401k membership
Total participants, beginning-of-year	2017-05-01	264
Total number of active participants reported on line 7a of the Form 5500	2017-05-01	0
Number of retired or separated participants receiving benefits	2017-05-01	0
Number of other retired or separated participants entitled to future benefits	2017-05-01	0
Total of all active and inactive participants	2017-05-01	0
2016: OMEGA SENIOR LIVING, LLC 2016 401k membership
Total participants, beginning-of-year	2016-05-01	201
Total number of active participants reported on line 7a of the Form 5500	2016-05-01	264
Total of all active and inactive participants	2016-05-01	264

Form 5500 Responses for OMEGA SENIOR LIVING, LLC

2017: OMEGA SENIOR LIVING, LLC 2017 form 5500 responses
2017-05-01	Type of plan entity	Single employer plan
2017-05-01	Submission has been amended	No
2017-05-01	This submission is the final filing	Yes
2017-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-05-01	Plan is a collectively bargained plan	No
2017-05-01	Plan funding arrangement – Insurance	Yes
2017-05-01	Plan benefit arrangement – Insurance	Yes
2016: OMEGA SENIOR LIVING, LLC 2016 form 5500 responses
2016-05-01	Type of plan entity	Single employer plan
2016-05-01	Plan funding arrangement – Insurance	Yes
2016-05-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	52
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $3,004
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	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	VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
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 $20,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,004
Insurance broker organization code?	3
Insurance broker name	PETRICH BENEFIT PLAN SERVICES INC

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

Policy contract number

000010229317

Policy instance

Insurance contract or identification number	000010229317
Number of Individuals Covered	16
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $1,122
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	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
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 $7,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,122
Insurance broker organization code?	3
Insurance broker name	PETRICH BENEFIT PLAN SERVICES INC

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

Policy contract number

000010175240

Policy instance

Insurance contract or identification number	000010175240
Number of Individuals Covered	283
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $1,383
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	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	GROUP ACCIDENTAL DEATH & DISMEMBERMENT
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 $11,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,382
Insurance broker organization code?	3
Insurance broker name	JAMES PETRICH

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Company Name:	OMEGA SENIOR LIVING, LLC
Employer identification number (EIN):	811853612
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities