|
CHRIS JENSEN HEALTH & REHABILITATION CENTER EMPLOYEE GROUP HEALTH PLAN
|
2012
|
270907035
|
2013-06-19
|
CHRIS JENSEN LLC
|
60
|
|
| File |
View Page
|
| Three-digit plan number (PN) |
502
|
| Effective date of plan |
2012-01-01
|
| Business code |
623000
|
| Sponsor’s telephone number |
2186256401
|
| Plan
sponsor’s DBA name |
CHRIS JENSEN HEALTH & REHABILITATION CENTER
|
| Plan sponsor’s mailing address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
| Plan sponsor’s
address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
Number of participants as of the end of the plan year
| Active participants |
58 |
| Retired or separated participants receiving
benefits |
2 |
| Other
retired or separated participants entitled to future benefits |
0 |
| Number of
participants
with
account balances as of the end of the plan year |
0 |
| Number of participants that
terminated
employment during the plan year with accrued benefits that were less than 100%
vested |
0 |
Signature of
| Role |
Plan administrator |
| Date |
2013-06-19 |
| Name of individual signing |
PAT VOELKER |
| Valid signature |
Filed with authorized/valid electronic signature |
|
|
|
EMPLOYEE GROUP DENTAL PLAN
|
2012
|
270907035
|
2013-06-19
|
CHRIS JENSEN LLC
|
67
|
|
| File |
View Page
|
| Three-digit plan number (PN) |
501
|
| Effective date of plan |
2010-01-01
|
| Business code |
623000
|
| Sponsor’s telephone number |
2186256401
|
| Plan
sponsor’s DBA name |
CHRIS JENSEN HEALTH & REHABILITATION CENTER
|
| Plan sponsor’s mailing address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
| Plan sponsor’s
address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
Number of participants as of the end of the plan year
| Active participants |
69 |
| Retired or separated participants receiving
benefits |
2 |
Signature of
| Role |
Plan administrator |
| Date |
2013-06-19 |
| Name of individual signing |
PAT VOELKER |
| Valid signature |
Filed with authorized/valid electronic signature |
|
|
|
EMPLOYEE GROUP LIFE PLAN
|
2012
|
270907035
|
2013-06-19
|
CHRIS JENSEN LLC
|
180
|
|
| File |
View Page
|
| Three-digit plan number (PN) |
510
|
| Effective date of plan |
2010-01-01
|
| Business code |
623000
|
| Sponsor’s telephone number |
2186256401
|
| Plan
sponsor’s DBA name |
CHRIS JENSEN HEALTH & REHABILITATION CENTER
|
| Plan sponsor’s mailing address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
| Plan sponsor’s
address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
Number of participants as of the end of the plan year
| Active participants |
180 |
| Retired or separated participants receiving
benefits |
6 |
Signature of
| Role |
Plan administrator |
| Date |
2013-06-19 |
| Name of individual signing |
PAT VOELKER |
| Valid signature |
Filed with authorized/valid electronic signature |
|
|
|
CHRIS JENSEN HEALTH & REHABILITATION CENTER EMPLOYEE GROUP HEALTH PLAN
|
2011
|
270907035
|
2012-06-05
|
CHRIS JENSEN LLC
|
61
|
|
| File |
View Page
|
| Three-digit plan number (PN) |
502
|
| Effective date of plan |
2011-01-01
|
| Business code |
623000
|
| Sponsor’s telephone number |
2186256401
|
| Plan
sponsor’s DBA name |
CHRIS JENSEN HEALTH & REHABILITATION CENTER
|
| Plan sponsor’s mailing address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
| Plan sponsor’s
address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
Plan administrator’s name and address
| Administrator’s EIN |
270907035 |
| Plan administrator’s name |
CHRIS JENSEN LLC |
| Plan administrator’s
address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811 |
| Administrator’s telephone number |
2186256401 |
Number of participants as of the end of the plan year
| Active participants |
58 |
| Retired or separated participants receiving
benefits |
2 |
| Other
retired or separated participants entitled to future benefits |
0 |
| Number of
participants
with
account balances as of the end of the plan year |
0 |
| Number of participants that
terminated
employment during the plan year with accrued benefits that were less than 100%
vested |
0 |
Signature of
| Role |
Plan administrator |
| Date |
2012-06-05 |
| Name of individual signing |
JILL HESS |
| Valid signature |
Filed with authorized/valid electronic signature |
|
|
|
EMPLOYEE GROUP DENTAL PLAN
|
2011
|
270907035
|
2012-06-08
|
CHRIS JENSEN LLC
|
74
|
|
| File |
View Page
|
| Three-digit plan number (PN) |
501
|
| Effective date of plan |
2010-01-01
|
| Business code |
623000
|
| Sponsor’s telephone number |
2186256401
|
| Plan
sponsor’s DBA name |
CHRIS JENSEN HEALTH & REHABILITATION CENTER
|
| Plan sponsor’s mailing address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
| Plan sponsor’s
address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
Plan administrator’s name and address
| Administrator’s EIN |
270907035 |
| Plan administrator’s name |
CHRIS JENSEN LLC |
| Plan administrator’s
address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811 |
| Administrator’s telephone number |
2186256401 |
Number of participants as of the end of the plan year
| Active participants |
75 |
| Retired or separated participants receiving
benefits |
1 |
| Other
retired or separated participants entitled to future benefits |
0 |
Signature of
| Role |
Plan administrator |
| Date |
2012-06-08 |
| Name of individual signing |
JILL HESS |
| Valid signature |
Filed with authorized/valid electronic signature |
|
|
|
EMPLOYEE GROUP LIFE PLAN
|
2011
|
270907035
|
2012-06-05
|
CHRIS JENSEN LLC
|
199
|
|
| File |
View Page
|
| Three-digit plan number (PN) |
510
|
| Effective date of plan |
2010-01-01
|
| Business code |
623000
|
| Sponsor’s telephone number |
2186256401
|
| Plan
sponsor’s DBA name |
CHRIS JENSEN HEALTH & REHABILITATION CENTER
|
| Plan sponsor’s mailing address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
| Plan sponsor’s
address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811
|
Plan administrator’s name and address
| Administrator’s EIN |
270907035 |
| Plan administrator’s name |
CHRIS JENSEN LLC |
| Plan administrator’s
address |
2501 RICE LAKE ROAD, DULUTH, MN, 55811 |
| Administrator’s telephone number |
2186256401 |
Number of participants as of the end of the plan year
| Active participants |
183 |
| Retired or separated participants receiving
benefits |
1 |
| Other
retired or separated participants entitled to future benefits |
0 |
| Deceased participants
whose
beneficiaries are receiving or are entitled to receive benefits |
0 |
Signature of
| Role |
Plan administrator |
| Date |
2012-06-05 |
| Name of individual signing |
JILL HESS |
| Valid signature |
Filed with authorized/valid electronic signature |
|
|
