401k Plan data: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST plan

NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 401k Plan overview

Plan Name	NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST
Plan identification number	501

NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

NORTH STATES INDUSTRIES, INC. has sponsored the creation of one or more 401k plans.

Company Name: NORTH STATES INDUSTRIES, INC.

Employer identification number (EIN): 410739037

NAIC Classification: 326100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-02-01
501 2011-11-01 KELLEY MUELLER
501 2010-11-01 KELLEY MUELLER
501 2009-11-01 DEAN WEISBECK
501 2008-11-01

Plan Statistics for NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST

401k plan membership statisitcs for NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST

Measure Date Value
2023: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2023 401k membership
Total participants, beginning-of-year 2023-02-01 121
Total number of active participants reported on line 7a of the Form 5500 2023-02-01 118
Number of retired or separated participants receiving benefits 2023-02-01 2
Number of other retired or separated participants entitled to future benefits 2023-02-01 0
Total of all active and inactive participants 2023-02-01 120
2011: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2011 401k membership
Total participants, beginning-of-year 2011-11-01 96
Total number of active participants reported on line 7a of the Form 5500 2011-11-01 91
Number of retired or separated participants receiving benefits 2011-11-01 2
Number of other retired or separated participants entitled to future benefits 2011-11-01 0
Total of all active and inactive participants 2011-11-01 93
2010: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2010 401k membership
Total participants, beginning-of-year 2010-11-01 115
Total number of active participants reported on line 7a of the Form 5500 2010-11-01 114
Number of retired or separated participants receiving benefits 2010-11-01 3
Number of other retired or separated participants entitled to future benefits 2010-11-01 0
Total of all active and inactive participants 2010-11-01 117
Total participants 2010-11-01 117
2009: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2009 401k membership
Total participants, beginning-of-year 2009-11-01 102
Total number of active participants reported on line 7a of the Form 5500 2009-11-01 115
Number of retired or separated participants receiving benefits 2009-11-01 0
Number of other retired or separated participants entitled to future benefits 2009-11-01 0
Total of all active and inactive participants 2009-11-01 115
Total participants 2009-11-01 115

Measure	Date	Value
2023: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2023 401k membership
Total participants, beginning-of-year	2023-02-01	121
Total number of active participants reported on line 7a of the Form 5500	2023-02-01	118
Number of retired or separated participants receiving benefits	2023-02-01	2
Number of other retired or separated participants entitled to future benefits	2023-02-01	0
Total of all active and inactive participants	2023-02-01	120
2011: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2011 401k membership
Total participants, beginning-of-year	2011-11-01	96
Total number of active participants reported on line 7a of the Form 5500	2011-11-01	91
Number of retired or separated participants receiving benefits	2011-11-01	2
Number of other retired or separated participants entitled to future benefits	2011-11-01	0
Total of all active and inactive participants	2011-11-01	93
2010: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2010 401k membership
Total participants, beginning-of-year	2010-11-01	115
Total number of active participants reported on line 7a of the Form 5500	2010-11-01	114
Number of retired or separated participants receiving benefits	2010-11-01	3
Number of other retired or separated participants entitled to future benefits	2010-11-01	0
Total of all active and inactive participants	2010-11-01	117
Total participants	2010-11-01	117
2009: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2009 401k membership
Total participants, beginning-of-year	2009-11-01	102
Total number of active participants reported on line 7a of the Form 5500	2009-11-01	115
Number of retired or separated participants receiving benefits	2009-11-01	0
Number of other retired or separated participants entitled to future benefits	2009-11-01	0
Total of all active and inactive participants	2009-11-01	115
Total participants	2009-11-01	115

Form 5500 Responses for NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST

2023: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2023 form 5500 responses
2023-02-01	Type of plan entity	Single employer plan
2023-02-01	First time form 5500 has been submitted	Yes
2023-02-01	Submission has been amended	No
2023-02-01	This submission is the final filing	No
2023-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-02-01	Plan is a collectively bargained plan	No
2023-02-01	Plan funding arrangement – Insurance	Yes
2023-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-02-01	Plan benefit arrangement – Insurance	Yes
2023-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2011 form 5500 responses
2011-11-01	Type of plan entity	Single employer plan
2011-11-01	Submission has been amended	No
2011-11-01	This submission is the final filing	No
2011-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-11-01	Plan is a collectively bargained plan	No
2011-11-01	Plan funding arrangement – Insurance	Yes
2011-11-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-11-01	Plan benefit arrangement – Insurance	Yes
2011-11-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2010 form 5500 responses
2010-11-01	Type of plan entity	Single employer plan
2010-11-01	Submission has been amended	No
2010-11-01	This submission is the final filing	No
2010-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-11-01	Plan is a collectively bargained plan	No
2010-11-01	Plan funding arrangement – Insurance	Yes
2010-11-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-11-01	Plan benefit arrangement – Insurance	Yes
2010-11-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2009 form 5500 responses
2009-11-01	Type of plan entity	Single employer plan
2009-11-01	Submission has been amended	No
2009-11-01	This submission is the final filing	No
2009-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-11-01	Plan is a collectively bargained plan	No
2009-11-01	Plan funding arrangement – Insurance	Yes
2009-11-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-11-01	Plan benefit arrangement – Insurance	Yes
2009-11-01	Plan benefit arrangement – General assets of the sponsor	Yes
2008: NORTH STATES INDUSTRIES, INC. EMPLOYEE BENEFIT PLAN TRUST 2008 form 5500 responses
2008-11-01	Type of plan entity	Single employer plan
2008-11-01	Submission has been amended	No
2008-11-01	This submission is the final filing	No
2008-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-11-01	Plan is a collectively bargained plan	No

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BH6L

Policy instance

Insurance contract or identification number	G000BH6L
Number of Individuals Covered	118
Insurance policy start date	2023-02-01
Insurance policy end date	2024-01-31
Total amount of commissions paid to insurance broker	USD $10,215
Total amount of fees paid to insurance company	USD $4,565
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 & 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 $67,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

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Company Name:	NORTH STATES INDUSTRIES, INC.
Employer identification number (EIN):	410739037
NAIC Classification:	326100

Plan id#	Filing Submission Date	Name of Administrator
501	2023-02-01
501	2011-11-01	KELLEY MUELLER
501	2010-11-01	KELLEY MUELLER
501	2009-11-01	DEAN WEISBECK
501	2008-11-01