401k Plan data: APEX FAMILY LLC HEALTH AND WELFARE BENEFIT PLAN plan

APEX FAMILY LLC HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	APEX FAMILY LLC HEALTH AND WELFARE BENEFIT PLAN
Plan identification number	501

APEX FAMILY LLC HEALTH AND WELFARE BENEFIT 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

APEX FAMILY LLC DBA GOODTURN TIRE & AUTO has sponsored the creation of one or more 401k plans.

Company Name: APEX FAMILY LLC DBA GOODTURN TIRE & AUTO

Employer identification number (EIN): 202769561

NAIC Classification: 441300
NAIC Description: Automotive Parts, Accessories, and Tire Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan APEX FAMILY LLC HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-03-01

Plan Statistics for APEX FAMILY LLC HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for APEX FAMILY LLC HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2023: APEX FAMILY LLC HEALTH AND WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year 2023-03-01 111
Total number of active participants reported on line 7a of the Form 5500 2023-03-01 184
Number of retired or separated participants receiving benefits 2023-03-01 2
Number of other retired or separated participants entitled to future benefits 2023-03-01 0
Total of all active and inactive participants 2023-03-01 186

Measure	Date	Value
2023: APEX FAMILY LLC HEALTH AND WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year	2023-03-01	111
Total number of active participants reported on line 7a of the Form 5500	2023-03-01	184
Number of retired or separated participants receiving benefits	2023-03-01	2
Number of other retired or separated participants entitled to future benefits	2023-03-01	0
Total of all active and inactive participants	2023-03-01	186

Form 5500 Responses for APEX FAMILY LLC HEALTH AND WELFARE BENEFIT PLAN

2023: APEX FAMILY LLC HEALTH AND WELFARE BENEFIT PLAN 2023 form 5500 responses
2023-03-01	Type of plan entity	Single employer plan
2023-03-01	First time form 5500 has been submitted	Yes
2023-03-01	Submission has been amended	No
2023-03-01	This submission is the final filing	No
2023-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-03-01	Plan is a collectively bargained plan	No
2023-03-01	Plan funding arrangement – Insurance	Yes
2023-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-03-01	Plan benefit arrangement – Insurance	Yes
2023-03-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

284338

Policy instance

Insurance contract or identification number	284338
Number of Individuals Covered	25
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $4,585
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

284338

Policy instance

Insurance contract or identification number	284338
Number of Individuals Covered	156
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $26,779
Total amount of fees paid to insurance company	USD $520
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
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

GLLV0C3CL

Policy instance

Insurance contract or identification number	GLLV0C3CL
Number of Individuals Covered	121
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $1,073
Total amount of fees paid to insurance company	USD $161
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,729
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

GLUG0C3CL

Policy instance

Insurance contract or identification number	GLUG0C3CL
Number of Individuals Covered	190
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $1,224
Total amount of fees paid to insurance company	USD $122
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,163
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

GUDB0C3CL

Policy instance

Insurance contract or identification number	GUDB0C3CL
Number of Individuals Covered	128
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $4,656
Total amount of fees paid to insurance company	USD $698
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $46,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	APEX FAMILY LLC DBA GOODTURN TIRE & AUTO
Employer identification number (EIN):	202769561
NAIC Classification:	441300
NAIC Description:	Automotive Parts, Accessories, and Tire Stores