401k Plan data: TIER ONE PROPERTY SERVICES GROUP HEALTH AND WELFARE BENEFITS PLAN plan

TIER ONE PROPERTY SERVICES GROUP HEALTH AND WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	TIER ONE PROPERTY SERVICES GROUP HEALTH AND WELFARE BENEFITS PLAN
Plan identification number	501

TIER ONE PROPERTY SERVICES GROUP HEALTH AND WELFARE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental

401k Sponsoring company profile

J & R INVESTMENTS, INC. DBA WOODLEY has sponsored the creation of one or more 401k plans.

Company Name: J & R INVESTMENTS, INC. DBA WOODLEY

Employer identification number (EIN): 431133097

NAIC Classification: 561720
NAIC Description: Janitorial Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TIER ONE PROPERTY SERVICES GROUP HEALTH AND WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-01-01 TERRY WOODLEY

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2017-01-01	TERRY WOODLEY

Plan Statistics for TIER ONE PROPERTY SERVICES GROUP HEALTH AND WELFARE BENEFITS PLAN

401k plan membership statisitcs for TIER ONE PROPERTY SERVICES GROUP HEALTH AND WELFARE BENEFITS PLAN

Measure Date Value
2017: TIER ONE PROPERTY SERVICES GROUP HEALTH AND WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 120
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 120

Measure	Date	Value
2017: TIER ONE PROPERTY SERVICES GROUP HEALTH AND WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	120
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	120

Form 5500 Responses for TIER ONE PROPERTY SERVICES GROUP HEALTH AND WELFARE BENEFITS PLAN

2017: TIER ONE PROPERTY SERVICES GROUP HEALTH AND WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	First time form 5500 has been submitted	Yes
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

37256000

Policy instance

Insurance contract or identification number	37256000
Number of Individuals Covered	128
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $13,281
Total amount of fees paid to insurance company	USD $11,861
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
Welfare Benefit Premiums Paid to Carrier	USD $771,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,281
Amount paid for insurance broker fees	11861
Additional information about fees paid to insurance broker	PROVISION OF ADMINISTRATIVE SERVICES TO BCBSKC
Insurance broker organization code?	3
Insurance broker name	TRUSS, LLC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1051748

Policy instance

Insurance contract or identification number	1051748
Number of Individuals Covered	161
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,920
Total amount of fees paid to insurance company	USD $423
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 $53,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,920
Amount paid for insurance broker fees	423
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	TRUSS, LLC

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Company Name:	J & R INVESTMENTS, INC. DBA WOODLEY
Employer identification number (EIN):	431133097
NAIC Classification:	561720
NAIC Description:	Janitorial Services