401k Plan data: SCOOTERBUG HEALTH AND WELFARE PLAN plan

SCOOTERBUG HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	SCOOTERBUG HEALTH AND WELFARE PLAN
Plan identification number	501

SCOOTERBUG HEALTH AND WELFARE PLAN 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 Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

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

Company Name: SCOOTERBUG, INC.

Employer identification number (EIN): 043168374

NAIC Classification: 541990
NAIC Description: All Other Professional, Scientific, and Technical Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SCOOTERBUG HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-08-01 SHANNON SPAULDING 2024-07-30

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-08-01	SHANNON SPAULDING	2024-07-30

Form 5500 Responses for SCOOTERBUG HEALTH AND WELFARE PLAN

2023: SCOOTERBUG HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-08-01	Type of plan entity	Single employer plan
2023-08-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2023-08-01	Plan funding arrangement – Insurance	Yes
2023-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-08-01	Plan benefit arrangement – Insurance	Yes
2023-08-01	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

613658

Policy instance

Insurance contract or identification number	613658
Number of Individuals Covered	178
Insurance policy start date	2023-08-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $6,692
Total amount of fees paid to insurance company	USD $48,163
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $707,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLUG0AXC7

Policy instance

Insurance contract or identification number	GLUG0AXC7
Number of Individuals Covered	204
Insurance policy start date	2023-08-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $586
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $3,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUG 0AXC7

Policy instance

Insurance contract or identification number	GUG 0AXC7
Number of Individuals Covered	204
Insurance policy start date	2023-08-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,564
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0AXC7

Policy instance

Insurance contract or identification number	GLTD0AXC7
Number of Individuals Covered	204
Insurance policy start date	2023-08-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,329
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0AXC7

Policy instance

Insurance contract or identification number	GVTL0AXC7
Number of Individuals Covered	67
Insurance policy start date	2023-08-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,198
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

SCOOTERBUG HEALTH AND WELFARE PLAN [EIN = 201206658]

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Company Name:	SCOOTERBUG, INC.
Employer identification number (EIN):	043168374
NAIC Classification:	541990
NAIC Description:	All Other Professional, Scientific, and Technical Services