401k Plan data: THE PEP BOYS-MANNY, MOE & JACK LLC HEALTH & WELFARE BENEFITS PROGRAM plan

THE PEP BOYS-MANNY, MOE & JACK LLC HEALTH & WELFARE BENEFITS PROGRAM 401k Plan overview

Plan Name	THE PEP BOYS-MANNY, MOE & JACK LLC HEALTH & WELFARE BENEFITS PROGRAM
Plan identification number	501

THE PEP BOYS-MANNY, MOE & JACK LLC HEALTH & WELFARE BENEFITS PROGRAM Benefits

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

401k Sponsoring company profile

THE PEP BOYS - MANNY, MOE & JACK LLC has sponsored the creation of one or more 401k plans.

Company Name: THE PEP BOYS - MANNY, MOE & JACK LLC

Employer identification number (EIN): 854254017

NAIC Classification: 441300
NAIC Description: Automotive Parts, Accessories, and Tire Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE PEP BOYS-MANNY, MOE & JACK LLC HEALTH & WELFARE BENEFITS PROGRAM

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 SHARON FISHMAN 2024-10-10

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-01-01	SHARON FISHMAN	2024-10-10

Plan Statistics for THE PEP BOYS-MANNY, MOE & JACK LLC HEALTH & WELFARE BENEFITS PROGRAM

401k plan membership statisitcs for THE PEP BOYS-MANNY, MOE & JACK LLC HEALTH & WELFARE BENEFITS PROGRAM

Measure Date Value
2023: THE PEP BOYS-MANNY, MOE & JACK LLC HEALTH & WELFARE BENEFITS PROGRAM 2023 401k membership
Total participants, beginning-of-year 2023-01-01 7,751
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 8,271
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 8,271
Number of employers contributing to the scheme 2023-01-01 0

Measure	Date	Value
2023: THE PEP BOYS-MANNY, MOE & JACK LLC HEALTH & WELFARE BENEFITS PROGRAM 2023 401k membership
Total participants, beginning-of-year	2023-01-01	7,751
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	8,271
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	8,271
Number of employers contributing to the scheme	2023-01-01	0

Form 5500 Responses for THE PEP BOYS-MANNY, MOE & JACK LLC HEALTH & WELFARE BENEFITS PROGRAM

2023: THE PEP BOYS-MANNY, MOE & JACK LLC HEALTH & WELFARE BENEFITS PROGRAM 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	First time form 5500 has been submitted	Yes
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )

Policy contract number

22137

Policy instance

Insurance contract or identification number	22137
Number of Individuals Covered	5598
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,726,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )

Policy contract number

30061966

Policy instance

Insurance contract or identification number	30061966
Number of Individuals Covered	3288
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $405,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

605396

Policy instance

Insurance contract or identification number	605396
Number of Individuals Covered	80
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $321,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MCS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60030 )

Policy contract number

79-791253

Policy instance

Insurance contract or identification number	79-791253
Number of Individuals Covered	364
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $67,965
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VALUEOPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 62199 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	8954
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $50,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

233363

Policy instance

Insurance contract or identification number	233363
Number of Individuals Covered	358
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,319,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VDT0980159

Policy instance

Insurance contract or identification number	VDT0980159
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $122,951
Total amount of fees paid to insurance company	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $2,655,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

Potentially related plans

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Company Name:	THE PEP BOYS - MANNY, MOE & JACK LLC
Employer identification number (EIN):	854254017
NAIC Classification:	441300
NAIC Description:	Automotive Parts, Accessories, and Tire Stores