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| Plan Name | TABLEROCK RESIDENTIAL |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | TABLEROCK RESIDENTIAL LLC |
| Employer identification number (EIN): | 833439602 |
| NAIC Classification: | 531310 |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2023-04-01 | RICH FERNANDEZ | 2024-10-22 | ||
| 501 | 2022-04-01 | RICH FERNANDEZ | 2023-08-31 |
| Measure | Date | Value |
|---|---|---|
| 2023: TABLEROCK RESIDENTIAL 2023 401k membership | ||
| Total participants, beginning-of-year | 2023-04-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-04-01 | 40 |
| Number of retired or separated participants receiving benefits | 2023-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2023-04-01 | 0 |
| Total of all active and inactive participants | 2023-04-01 | 40 |
| Number of employers contributing to the scheme | 2023-04-01 | 0 |
| 2022: TABLEROCK RESIDENTIAL 2022 401k membership | ||
| Total participants, beginning-of-year | 2022-04-01 | 106 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-04-01 | 101 |
| Number of retired or separated participants receiving benefits | 2022-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-04-01 | 0 |
| Total of all active and inactive participants | 2022-04-01 | 101 |
| Number of employers contributing to the scheme | 2022-04-01 | 0 |
| 2023: TABLEROCK RESIDENTIAL 2023 form 5500 responses | ||
|---|---|---|
| 2023-04-01 | Type of plan entity | Single employer plan |
| 2023-04-01 | Plan funding arrangement – Insurance | Yes |
| 2023-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2022: TABLEROCK RESIDENTIAL 2022 form 5500 responses | ||
| 2022-04-01 | Type of plan entity | Single employer plan |
| 2022-04-01 | First time form 5500 has been submitted | Yes |
| 2022-04-01 | Plan funding arrangement – Insurance | Yes |
| 2022-04-01 | Plan benefit arrangement – Insurance | Yes |
| BLUE CROSS OF IDAHO HEALTH SERVICE INC. (National Association of Insurance Commissioners NAIC id number: 60095 ) | |||||||||||||||||||||||||
| Policy contract number | 10037683 | ||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||
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| BLUE CROSS OF IDAHO HEALTH SERVICE INC. (National Association of Insurance Commissioners NAIC id number: 60095 ) | |||||||||||||||||||||||||
| Policy contract number | 10037683 | ||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||
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