401k Plan data: LUSCOMBE ENGINEERING, INC. plan

LUSCOMBE ENGINEERING, INC. 401k Plan overview

Plan Name	LUSCOMBE ENGINEERING, INC.
Plan identification number	501

LUSCOMBE ENGINEERING, INC. Benefits

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

401k Sponsoring company profile

LUSCOMBE ENGINEERING, INC. has sponsored the creation of one or more 401k plans.

Company Name: LUSCOMBE ENGINEERING, INC.

Employer identification number (EIN): 832879620

NAIC Classification: 425110
NAIC Description: Business to Business Electronic Markets

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LUSCOMBE ENGINEERING, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-12-01 DOUG CANTERBURY 2022-06-27
501 2019-12-01 DOUG CANTERBURY 2021-06-22

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2020-12-01	DOUG CANTERBURY	2022-06-27
501	2019-12-01	DOUG CANTERBURY	2021-06-22

Plan Statistics for LUSCOMBE ENGINEERING, INC.

401k plan membership statisitcs for LUSCOMBE ENGINEERING, INC.

Measure Date Value
2020: LUSCOMBE ENGINEERING, INC. 2020 401k membership
Total participants, beginning-of-year 2020-12-01 29
Total number of active participants reported on line 7a of the Form 5500 2020-12-01 29
Number of retired or separated participants receiving benefits 2020-12-01 0
Number of other retired or separated participants entitled to future benefits 2020-12-01 0
Total of all active and inactive participants 2020-12-01 29
2019: LUSCOMBE ENGINEERING, INC. 2019 401k membership
Total participants, beginning-of-year 2019-12-01 32
Total number of active participants reported on line 7a of the Form 5500 2019-12-01 29
Number of retired or separated participants receiving benefits 2019-12-01 0
Number of other retired or separated participants entitled to future benefits 2019-12-01 0
Total of all active and inactive participants 2019-12-01 29

Measure	Date	Value
2020: LUSCOMBE ENGINEERING, INC. 2020 401k membership
Total participants, beginning-of-year	2020-12-01	29
Total number of active participants reported on line 7a of the Form 5500	2020-12-01	29
Number of retired or separated participants receiving benefits	2020-12-01	0
Number of other retired or separated participants entitled to future benefits	2020-12-01	0
Total of all active and inactive participants	2020-12-01	29
2019: LUSCOMBE ENGINEERING, INC. 2019 401k membership
Total participants, beginning-of-year	2019-12-01	32
Total number of active participants reported on line 7a of the Form 5500	2019-12-01	29
Number of retired or separated participants receiving benefits	2019-12-01	0
Number of other retired or separated participants entitled to future benefits	2019-12-01	0
Total of all active and inactive participants	2019-12-01	29

Form 5500 Responses for LUSCOMBE ENGINEERING, INC.

2020: LUSCOMBE ENGINEERING, INC. 2020 form 5500 responses
2020-12-01	Type of plan entity	Single employer plan
2020-12-01	Submission has been amended	No
2020-12-01	This submission is the final filing	No
2020-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-12-01	Plan is a collectively bargained plan	No
2020-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-12-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: LUSCOMBE ENGINEERING, INC. 2019 form 5500 responses
2019-12-01	Type of plan entity	Single employer plan
2019-12-01	Submission has been amended	No
2019-12-01	This submission is the final filing	No
2019-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-12-01	Plan is a collectively bargained plan	No
2019-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-12-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00621184

Policy instance

Insurance contract or identification number	00621184
Number of Individuals Covered	29
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $12,509
Total amount of fees paid to insurance company	USD $5,002
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 $166,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,509
Amount paid for insurance broker fees	5002
Additional information about fees paid to insurance broker	SERVICE / GENERAL AGENT FEES
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00621184

Policy instance

Insurance contract or identification number	00621184
Number of Individuals Covered	29
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $12,045
Total amount of fees paid to insurance company	USD $4,750
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	Yes
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 $103,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,045
Amount paid for insurance broker fees	4750
Additional information about fees paid to insurance broker	SERVICE / GEN. AGENT FEES
Insurance broker organization code?	3

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Company Name:	LUSCOMBE ENGINEERING, INC.
Employer identification number (EIN):	832879620
NAIC Classification:	425110
NAIC Description:	Business to Business Electronic Markets