401k Plan data: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE plan

EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 401k Plan overview

Plan Name	EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE
Plan identification number	501

EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

DRB SYSTEMS, LLC has sponsored the creation of one or more 401k plans.

Company Name: DRB SYSTEMS, LLC

Employer identification number (EIN): 341455539

NAIC Classification: 541519
NAIC Description: Other Computer Related Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-01-01 MATTHEW J DOODS
501 2014-12-01 MATTHEW DODDS
501 2013-12-01 MATTHEW DODDS
501 2012-12-01 MATTHEW DODDS
501 2011-12-01 MATTHEW DODDS

Plan id#	Filing Submission Date	Name of Administrator
501	2015-01-01	MATTHEW J DOODS
501	2014-12-01	MATTHEW DODDS
501	2013-12-01	MATTHEW DODDS
501	2012-12-01	MATTHEW DODDS
501	2011-12-01	MATTHEW DODDS

Plan Statistics for EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE

401k plan membership statisitcs for EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE

Measure Date Value
2015: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2015 401k membership
Total participants, beginning-of-year 2015-01-01 138
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 0
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 0
2014: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2014 401k membership
Total participants, beginning-of-year 2014-12-01 137
Total number of active participants reported on line 7a of the Form 5500 2014-12-01 137
Number of retired or separated participants receiving benefits 2014-12-01 0
Number of other retired or separated participants entitled to future benefits 2014-12-01 0
Total of all active and inactive participants 2014-12-01 137
2013: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2013 401k membership
Total participants, beginning-of-year 2013-12-01 120
Total number of active participants reported on line 7a of the Form 5500 2013-12-01 137
Number of retired or separated participants receiving benefits 2013-12-01 0
Number of other retired or separated participants entitled to future benefits 2013-12-01 0
Total of all active and inactive participants 2013-12-01 137
2012: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2012 401k membership
Total participants, beginning-of-year 2012-12-01 109
Total number of active participants reported on line 7a of the Form 5500 2012-12-01 120
Number of retired or separated participants receiving benefits 2012-12-01 0
Number of other retired or separated participants entitled to future benefits 2012-12-01 0
Total of all active and inactive participants 2012-12-01 120
2011: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2011 401k membership
Total participants, beginning-of-year 2011-12-01 100
Total number of active participants reported on line 7a of the Form 5500 2011-12-01 109
Number of retired or separated participants receiving benefits 2011-12-01 0
Number of other retired or separated participants entitled to future benefits 2011-12-01 0
Total of all active and inactive participants 2011-12-01 109

Measure	Date	Value
2015: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2015 401k membership
Total participants, beginning-of-year	2015-01-01	138
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	0
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	0
2014: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2014 401k membership
Total participants, beginning-of-year	2014-12-01	137
Total number of active participants reported on line 7a of the Form 5500	2014-12-01	137
Number of retired or separated participants receiving benefits	2014-12-01	0
Number of other retired or separated participants entitled to future benefits	2014-12-01	0
Total of all active and inactive participants	2014-12-01	137
2013: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2013 401k membership
Total participants, beginning-of-year	2013-12-01	120
Total number of active participants reported on line 7a of the Form 5500	2013-12-01	137
Number of retired or separated participants receiving benefits	2013-12-01	0
Number of other retired or separated participants entitled to future benefits	2013-12-01	0
Total of all active and inactive participants	2013-12-01	137
2012: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2012 401k membership
Total participants, beginning-of-year	2012-12-01	109
Total number of active participants reported on line 7a of the Form 5500	2012-12-01	120
Number of retired or separated participants receiving benefits	2012-12-01	0
Number of other retired or separated participants entitled to future benefits	2012-12-01	0
Total of all active and inactive participants	2012-12-01	120
2011: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2011 401k membership
Total participants, beginning-of-year	2011-12-01	100
Total number of active participants reported on line 7a of the Form 5500	2011-12-01	109
Number of retired or separated participants receiving benefits	2011-12-01	0
Number of other retired or separated participants entitled to future benefits	2011-12-01	0
Total of all active and inactive participants	2011-12-01	109

Form 5500 Responses for EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE

2015: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	Yes
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2014 form 5500 responses
2014-12-01	Type of plan entity	Single employer plan
2014-12-01	Submission has been amended	No
2014-12-01	This submission is the final filing	No
2014-12-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2014-12-01	Plan is a collectively bargained plan	No
2014-12-01	Plan funding arrangement – Insurance	Yes
2014-12-01	Plan benefit arrangement – Insurance	Yes
2013: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2013 form 5500 responses
2013-12-01	Type of plan entity	Single employer plan
2013-12-01	Submission has been amended	No
2013-12-01	This submission is the final filing	No
2013-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-12-01	Plan is a collectively bargained plan	No
2013-12-01	Plan funding arrangement – Insurance	Yes
2013-12-01	Plan benefit arrangement – Insurance	Yes
2012: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2012 form 5500 responses
2012-12-01	Type of plan entity	Single employer plan
2012-12-01	Submission has been amended	No
2012-12-01	This submission is the final filing	No
2012-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-12-01	Plan is a collectively bargained plan	No
2012-12-01	Plan funding arrangement – Insurance	Yes
2012-12-01	Plan benefit arrangement – Insurance	Yes
2011: EMPLOYEE LIFE, ADD, STD, LTD, VOLUNTARY LIFE 2011 form 5500 responses
2011-12-01	Type of plan entity	Single employer plan
2011-12-01	First time form 5500 has been submitted	Yes
2011-12-01	Submission has been amended	No
2011-12-01	This submission is the final filing	No
2011-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-12-01	Plan is a collectively bargained plan	No
2011-12-01	Plan funding arrangement – Insurance	Yes
2011-12-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

145058

Policy instance

Insurance contract or identification number	145058
Number of Individuals Covered	156
Insurance policy start date	2015-01-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $2,084
Total amount of fees paid to insurance company	USD $55
Are there contracts with allocated funds for individual policies?	No
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
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 $17,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,235
Insurance broker organization code?	3
Amount paid for insurance broker fees	55
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	USI INSURANCE SERVICES, LLC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

145058

Policy instance

Insurance contract or identification number	145058
Number of Individuals Covered	137
Insurance policy start date	2014-12-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
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?	Yes

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

145058

Policy instance

Insurance contract or identification number	145058
Number of Individuals Covered	137
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $3,912
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
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 $34,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,912
Insurance broker organization code?	3
Insurance broker name	RAMSBURG INSURANCE AGENCY, INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

145058

Policy instance

Insurance contract or identification number	145058
Number of Individuals Covered	120
Insurance policy start date	2012-12-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $3,609
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
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 $30,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,609
Insurance broker organization code?	3
Insurance broker name	RAMSBURG INSURANCE AGENCY, INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

145058

Policy instance

Insurance contract or identification number	145058
Number of Individuals Covered	109
Insurance policy start date	2011-12-01
Insurance policy end date	2012-11-30
Total amount of commissions paid to insurance broker	USD $3,607
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
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 $30,291
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	DRB SYSTEMS, LLC
Employer identification number (EIN):	341455539
NAIC Classification:	541519
NAIC Description:	Other Computer Related Services