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| Plan Name | SRCV, LLC WELFARE BENEFIT PLAN |
| Plan identification number | 505 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | SRCV, LLC |
| Employer identification number (EIN): | 861049313 |
| NAIC Classification: | 623000 |
| NAIC Description: | Nursing and Residential Care Facilities |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 505 | 2020-03-01 |
| Measure | Date | Value |
|---|---|---|
| 2020: SRCV, LLC WELFARE BENEFIT PLAN 2020 401k membership | ||
| Total participants, beginning-of-year | 2020-03-01 | 131 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-03-01 | 131 |
| Total of all active and inactive participants | 2020-03-01 | 131 |
| Total participants | 2020-03-01 | 131 |
| 2020: SRCV, LLC WELFARE BENEFIT PLAN 2020 form 5500 responses | ||
|---|---|---|
| 2020-03-01 | Type of plan entity | Mulitple employer plan |
| 2020-03-01 | First time form 5500 has been submitted | Yes |
| 2020-03-01 | Submission has been amended | No |
| 2020-03-01 | This submission is the final filing | No |
| 2020-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-03-01 | Plan is a collectively bargained plan | No |
| 2020-03-01 | Plan funding arrangement – Insurance | Yes |
| 2020-03-01 | Plan benefit arrangement – Insurance | Yes |
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) | |
| Policy contract number | 31423 |
| Policy instance | 1 |
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) | |
| Policy contract number | 19475 |
| Policy instance | 2 |
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) | |
| Policy contract number | 19476 |
| Policy instance | 3 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) | |
| Policy contract number | GL 157655 |
| Policy instance | 4 |
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