401k Plan data: ACCIDENTAL DEATH AND DISMEMBERMENT plan

ACCIDENTAL DEATH AND DISMEMBERMENT 401k Plan overview

Plan Name	ACCIDENTAL DEATH AND DISMEMBERMENT
Plan identification number	517

ACCIDENTAL DEATH AND DISMEMBERMENT Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

INDIAN HEAD INDUSTRIES, INC. has sponsored the creation of one or more 401k plans.

Company Name: INDIAN HEAD INDUSTRIES, INC.

Employer identification number (EIN): 382511555

NAIC Classification: 336300

Additional information about INDIAN HEAD INDUSTRIES, INC.

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 2027130

More information about INDIAN HEAD INDUSTRIES, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ACCIDENTAL DEATH AND DISMEMBERMENT

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
517 2013-04-01
517 2012-04-01 JEFFREY PARKER SUSAN PARKER 2014-01-10
517 2011-04-01 JEFFREY PARKER SUSAN PARKER 2013-01-08
517 2010-04-01 JEFFREY PARKER SUSAN PFEIFFER 2012-01-11
517 2009-04-01 JEFFREY PARKER SUSAN PFEIFFER 2011-01-14

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
517	2013-04-01
517	2012-04-01	JEFFREY PARKER	SUSAN PARKER	2014-01-10
517	2011-04-01	JEFFREY PARKER	SUSAN PARKER	2013-01-08
517	2010-04-01	JEFFREY PARKER	SUSAN PFEIFFER	2012-01-11
517	2009-04-01	JEFFREY PARKER	SUSAN PFEIFFER	2011-01-14

Plan Statistics for ACCIDENTAL DEATH AND DISMEMBERMENT

401k plan membership statisitcs for ACCIDENTAL DEATH AND DISMEMBERMENT

Measure Date Value
2013: ACCIDENTAL DEATH AND DISMEMBERMENT 2013 401k membership
Total participants, beginning-of-year 2013-04-01 41
Total number of active participants reported on line 7a of the Form 5500 2013-04-01 0
Number of retired or separated participants receiving benefits 2013-04-01 0
Number of other retired or separated participants entitled to future benefits 2013-04-01 0
Total of all active and inactive participants 2013-04-01 0
2012: ACCIDENTAL DEATH AND DISMEMBERMENT 2012 401k membership
Total participants, beginning-of-year 2012-04-01 43
Total number of active participants reported on line 7a of the Form 5500 2012-04-01 41
Number of retired or separated participants receiving benefits 2012-04-01 0
Number of other retired or separated participants entitled to future benefits 2012-04-01 0
Total of all active and inactive participants 2012-04-01 41
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-04-01 0
Total participants 2012-04-01 41
2011: ACCIDENTAL DEATH AND DISMEMBERMENT 2011 401k membership
Total participants, beginning-of-year 2011-04-01 45
Total number of active participants reported on line 7a of the Form 5500 2011-04-01 43
Number of retired or separated participants receiving benefits 2011-04-01 0
Number of other retired or separated participants entitled to future benefits 2011-04-01 0
Total of all active and inactive participants 2011-04-01 43
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-04-01 0
Total participants 2011-04-01 43
2010: ACCIDENTAL DEATH AND DISMEMBERMENT 2010 401k membership
Total participants, beginning-of-year 2010-04-01 50
Total number of active participants reported on line 7a of the Form 5500 2010-04-01 45
Number of retired or separated participants receiving benefits 2010-04-01 0
Number of other retired or separated participants entitled to future benefits 2010-04-01 0
Total of all active and inactive participants 2010-04-01 45
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-04-01 0
Total participants 2010-04-01 45
2009: ACCIDENTAL DEATH AND DISMEMBERMENT 2009 401k membership
Total participants, beginning-of-year 2009-04-01 54
Total number of active participants reported on line 7a of the Form 5500 2009-04-01 50
Number of retired or separated participants receiving benefits 2009-04-01 0
Number of other retired or separated participants entitled to future benefits 2009-04-01 0
Total of all active and inactive participants 2009-04-01 50
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-04-01 0
Total participants 2009-04-01 50

Measure	Date	Value
2013: ACCIDENTAL DEATH AND DISMEMBERMENT 2013 401k membership
Total participants, beginning-of-year	2013-04-01	41
Total number of active participants reported on line 7a of the Form 5500	2013-04-01	0
Number of retired or separated participants receiving benefits	2013-04-01	0
Number of other retired or separated participants entitled to future benefits	2013-04-01	0
Total of all active and inactive participants	2013-04-01	0
2012: ACCIDENTAL DEATH AND DISMEMBERMENT 2012 401k membership
Total participants, beginning-of-year	2012-04-01	43
Total number of active participants reported on line 7a of the Form 5500	2012-04-01	41
Number of retired or separated participants receiving benefits	2012-04-01	0
Number of other retired or separated participants entitled to future benefits	2012-04-01	0
Total of all active and inactive participants	2012-04-01	41
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-04-01	0
Total participants	2012-04-01	41
2011: ACCIDENTAL DEATH AND DISMEMBERMENT 2011 401k membership
Total participants, beginning-of-year	2011-04-01	45
Total number of active participants reported on line 7a of the Form 5500	2011-04-01	43
Number of retired or separated participants receiving benefits	2011-04-01	0
Number of other retired or separated participants entitled to future benefits	2011-04-01	0
Total of all active and inactive participants	2011-04-01	43
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-04-01	0
Total participants	2011-04-01	43
2010: ACCIDENTAL DEATH AND DISMEMBERMENT 2010 401k membership
Total participants, beginning-of-year	2010-04-01	50
Total number of active participants reported on line 7a of the Form 5500	2010-04-01	45
Number of retired or separated participants receiving benefits	2010-04-01	0
Number of other retired or separated participants entitled to future benefits	2010-04-01	0
Total of all active and inactive participants	2010-04-01	45
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-04-01	0
Total participants	2010-04-01	45
2009: ACCIDENTAL DEATH AND DISMEMBERMENT 2009 401k membership
Total participants, beginning-of-year	2009-04-01	54
Total number of active participants reported on line 7a of the Form 5500	2009-04-01	50
Number of retired or separated participants receiving benefits	2009-04-01	0
Number of other retired or separated participants entitled to future benefits	2009-04-01	0
Total of all active and inactive participants	2009-04-01	50
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-04-01	0
Total participants	2009-04-01	50

Form 5500 Responses for ACCIDENTAL DEATH AND DISMEMBERMENT

2013: ACCIDENTAL DEATH AND DISMEMBERMENT 2013 form 5500 responses
2013-04-01	Type of plan entity	Single employer plan
2013-04-01	Submission has been amended	Yes
2013-04-01	This submission is the final filing	Yes
2013-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-04-01	Plan is a collectively bargained plan	No
2013-04-01	Plan funding arrangement – Insurance	Yes
2013-04-01	Plan benefit arrangement – Insurance	Yes
2012: ACCIDENTAL DEATH AND DISMEMBERMENT 2012 form 5500 responses
2012-04-01	Type of plan entity	Single employer plan
2012-04-01	Submission has been amended	No
2012-04-01	This submission is the final filing	No
2012-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-04-01	Plan is a collectively bargained plan	No
2012-04-01	Plan funding arrangement – Insurance	Yes
2012-04-01	Plan benefit arrangement – Insurance	Yes
2011: ACCIDENTAL DEATH AND DISMEMBERMENT 2011 form 5500 responses
2011-04-01	Type of plan entity	Single employer plan
2011-04-01	Submission has been amended	No
2011-04-01	This submission is the final filing	No
2011-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-04-01	Plan is a collectively bargained plan	No
2011-04-01	Plan funding arrangement – Insurance	Yes
2011-04-01	Plan benefit arrangement – Insurance	Yes
2010: ACCIDENTAL DEATH AND DISMEMBERMENT 2010 form 5500 responses
2010-04-01	Type of plan entity	Single employer plan
2010-04-01	Submission has been amended	No
2010-04-01	This submission is the final filing	No
2010-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-04-01	Plan is a collectively bargained plan	No
2010-04-01	Plan funding arrangement – Insurance	Yes
2010-04-01	Plan benefit arrangement – Insurance	Yes
2009: ACCIDENTAL DEATH AND DISMEMBERMENT 2009 form 5500 responses
2009-04-01	Type of plan entity	Single employer plan
2009-04-01	Submission has been amended	No
2009-04-01	This submission is the final filing	No
2009-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-04-01	Plan is a collectively bargained plan	No
2009-04-01	Plan funding arrangement – Insurance	Yes
2009-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK965042

Policy instance

Insurance contract or identification number	OK965042
Number of Individuals Covered	36
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $202
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	No
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
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 $4,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $202
Insurance broker organization code?	3
Insurance broker name	BENEFIT CONTROLS OF THE CAROLINAS

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Company Name:	INDIAN HEAD INDUSTRIES, INC.
Employer identification number (EIN):	382511555
NAIC Classification:	336300

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	2027130