401k Plan data: REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN plan

REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN
Plan identification number	501

REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

REVIVE HEALTH SENIOR CARE, LLC has sponsored the creation of one or more 401k plans.

Company Name: REVIVE HEALTH SENIOR CARE, LLC

Employer identification number (EIN): 832773153

NAIC Classification: 111100
NAIC Description: Oilseed and Grain Farming

Form 5500 Filing Information

Submission information for form 5500 for 401k plan REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-02-01 CHELSEY GRAY 2024-07-09

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-02-01	CHELSEY GRAY	2024-07-09

Form 5500 Responses for REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN

2023: REVIVE HEALTH SENIOR CARE, LLC HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-02-01	Type of plan entity	Single employer plan
2023-02-01	Plan funding arrangement – Insurance	Yes
2023-02-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )

Policy contract number

L05139

Policy instance

Insurance contract or identification number	L05139
Number of Individuals Covered	120
Insurance policy start date	2023-02-01
Insurance policy end date	2024-01-31
Total amount of commissions paid to insurance broker	USD $27,767
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $752,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 95473 )

Policy contract number

L05139

Policy instance

Insurance contract or identification number	L05139
Number of Individuals Covered	151
Insurance policy start date	2023-02-01
Insurance policy end date	2024-01-31
Total amount of commissions paid to insurance broker	USD $31,033
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $840,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

GLUG0C3G6

Policy instance

Insurance contract or identification number	GLUG0C3G6
Number of Individuals Covered	322
Insurance policy start date	2023-02-01
Insurance policy end date	2024-01-31
Total amount of commissions paid to insurance broker	USD $9,962
Total amount of fees paid to insurance company	USD $2,096
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
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	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $145,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

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Company Name:	REVIVE HEALTH SENIOR CARE, LLC
Employer identification number (EIN):	832773153
NAIC Classification:	111100
NAIC Description:	Oilseed and Grain Farming