401k Plan data: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN plan

LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN
Plan identification number	501

LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE 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)
Long-term disability cover
Death benefits (include travel accident but not life insurance)
Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

LAKESIDE TLF, LLC has sponsored the creation of one or more 401k plans.

Company Name: LAKESIDE TLF, LLC

Employer identification number (EIN): 820754395

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 ANNETTE SANDOVAL 2024-09-19
501 2022-01-01 ANNETTE SANDOVAL 2023-07-27
501 2021-01-01 ANNETTE SANDOVAL 2022-09-01
501 2020-01-01 ANNETTE SANDOVAL 2021-09-16
501 2019-01-01 ANNETTE SANDOVAL 2020-04-14
501 2017-01-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2023-01-01	ANNETTE SANDOVAL	2024-09-19
501	2022-01-01	ANNETTE SANDOVAL	2023-07-27
501	2021-01-01	ANNETTE SANDOVAL	2022-09-01
501	2020-01-01	ANNETTE SANDOVAL	2021-09-16
501	2019-01-01	ANNETTE SANDOVAL	2020-04-14
501	2017-01-01

Plan Statistics for LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN

401k plan membership statisitcs for LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN

Measure Date Value
2023: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 183
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 200
Number of retired or separated participants receiving benefits 2023-01-01 1
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 201
Number of employers contributing to the scheme 2023-01-01 0
2022: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 201
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 253
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 13
Total of all active and inactive participants 2022-01-01 266
Number of employers contributing to the scheme 2022-01-01 0
2021: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 201
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 83
Number of retired or separated participants receiving benefits 2021-01-01 0
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 83
Number of employers contributing to the scheme 2021-01-01 0
2020: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 201
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 201
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 201
Number of employers contributing to the scheme 2020-01-01 0
2019: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 130
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 78
Number of retired or separated participants receiving benefits 2019-01-01 0
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 78
Number of employers contributing to the scheme 2019-01-01 0
2017: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 141
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 124
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 124

Measure	Date	Value
2023: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	183
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	200
Number of retired or separated participants receiving benefits	2023-01-01	1
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	201
Number of employers contributing to the scheme	2023-01-01	0
2022: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	201
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	253
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	13
Total of all active and inactive participants	2022-01-01	266
Number of employers contributing to the scheme	2022-01-01	0
2021: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	201
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	83
Number of retired or separated participants receiving benefits	2021-01-01	0
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	83
Number of employers contributing to the scheme	2021-01-01	0
2020: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	201
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	201
Number of retired or separated participants receiving benefits	2020-01-01	0
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	201
Number of employers contributing to the scheme	2020-01-01	0
2019: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	130
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	78
Number of retired or separated participants receiving benefits	2019-01-01	0
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	78
Number of employers contributing to the scheme	2019-01-01	0
2017: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	124
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	124

Form 5500 Responses for LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN

2023: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Submission has been amended	Yes
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS 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 benefit arrangement – Insurance	Yes
2021: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS 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 benefit arrangement – Insurance	Yes
2020: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS 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 benefit arrangement – Insurance	Yes
2019: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS 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 benefit arrangement – Insurance	Yes
2017: LAKESIDE SNF, LLC & LAKESIDE TLF, LLC & LAKESIDE TLF PED, LLC WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GVTL0AV7N

Policy instance

Insurance contract or identification number	GVTL0AV7N
Number of Individuals Covered	101
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,716
Total amount of fees paid to insurance company	USD $3,771
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $87,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

K3422

Policy instance

Insurance contract or identification number	K3422
Number of Individuals Covered	80
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $33,915
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0AV7N

Policy instance

Insurance contract or identification number	GVTL0AV7N
Number of Individuals Covered	206
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,470
Total amount of fees paid to insurance company	USD $5,003
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $64,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

143198

Policy instance

Insurance contract or identification number	143198
Number of Individuals Covered	90
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $28,614
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $541,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

143198

Policy instance

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 )

Policy contract number

E6048-8E930X

Policy instance

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

39078

Policy instance

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60049 )

Policy contract number

E5187638

Policy instance

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

51488

Policy instance

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

Policy contract number

GVTL0AV7N

Policy instance

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50030976

Policy instance

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50030976

Policy instance

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

Policy contract number

GVTL0AV7N

Policy instance

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60049 )

Policy contract number

E5187638

Policy instance

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

39078

Policy instance

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 )

Policy contract number

E6048-8E930X

Policy instance

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

Policy contract number

143198

Policy instance

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

56571

Policy instance

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

DM12072401

Policy instance

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60049 )

Policy contract number

E5187638

Policy instance

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 )

Policy contract number

E6048-8E930X

Policy instance

ADVANTICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 12278 )

Policy contract number

12072401

Policy instance

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

Policy contract number

GVTL0AV7N

Policy instance

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50030976

Policy instance

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

Policy contract number

GVTL0AV7N

Policy instance

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

Policy contract number

GUC0AV7N

Policy instance

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

Policy contract number

GUPR0AV7N

Policy instance

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

Policy contract number

GUDB0AV7N

Policy instance

ADVANTICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 12278 )

Policy contract number

12072401

Policy instance

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

56571

Policy instance

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Company Name:	LAKESIDE TLF, LLC
Employer identification number (EIN):	820754395
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities