401k Plan data: MARBUCCO CORP. DBA GRANITE STATE GLASS GROUP INSURANCE PLAN plan

MARBUCCO CORP. DBA GRANITE STATE GLASS GROUP INSURANCE PLAN 401k Plan overview

Plan Name	MARBUCCO CORP. DBA GRANITE STATE GLASS GROUP INSURANCE PLAN
Plan identification number	501

MARBUCCO CORP. DBA GRANITE STATE GLASS GROUP INSURANCE PLAN Benefits

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

401k Sponsoring company profile

GRANITE STATE GLASS has sponsored the creation of one or more 401k plans.

Company Name: GRANITE STATE GLASS

Employer identification number (EIN): 020369938

NAIC Classification: 238900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MARBUCCO CORP. DBA GRANITE STATE GLASS GROUP INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01

Plan Statistics for MARBUCCO CORP. DBA GRANITE STATE GLASS GROUP INSURANCE PLAN

401k plan membership statisitcs for MARBUCCO CORP. DBA GRANITE STATE GLASS GROUP INSURANCE PLAN

Measure Date Value
2022: MARBUCCO CORP. DBA GRANITE STATE GLASS GROUP INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 161
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 164
Number of retired or separated participants receiving benefits 2022-07-01 1
Number of other retired or separated participants entitled to future benefits 2022-07-01 0
Total of all active and inactive participants 2022-07-01 165

Measure	Date	Value
2022: MARBUCCO CORP. DBA GRANITE STATE GLASS GROUP INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	161
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	164
Number of retired or separated participants receiving benefits	2022-07-01	1
Number of other retired or separated participants entitled to future benefits	2022-07-01	0
Total of all active and inactive participants	2022-07-01	165

Form 5500 Responses for MARBUCCO CORP. DBA GRANITE STATE GLASS GROUP INSURANCE PLAN

2022: MARBUCCO CORP. DBA GRANITE STATE GLASS GROUP INSURANCE PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	First time form 5500 has been submitted	Yes
2022-07-01	Submission has been amended	No
2022-07-01	This submission is the final filing	No
2022-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-07-01	Plan is a collectively bargained plan	No
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26921 )

Policy contract number

SL31000320-221

Policy instance

Insurance contract or identification number	SL31000320-221
Number of Individuals Covered	165
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
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
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 $362,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RED TREE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 13646 )

Policy contract number

000912128

Policy instance

Insurance contract or identification number	000912128
Number of Individuals Covered	253
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $2,009
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	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 $17,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,747
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	NONE
Insurance broker organization code?	3

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Company Name:	GRANITE STATE GLASS
Employer identification number (EIN):	020369938
NAIC Classification:	238900