401k Plan data: TB KAWASHIMA VISION PLAN plan

TB KAWASHIMA VISION PLAN 401k Plan overview

Plan Name	TB KAWASHIMA VISION PLAN
Plan identification number	502

TB KAWASHIMA VISION PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

TB KAWASHIMA USA INC. has sponsored the creation of one or more 401k plans.

Company Name: TB KAWASHIMA USA INC.

Employer identification number (EIN): 043679418

NAIC Classification: 314000
NAIC Description: Textile Product Mills

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TB KAWASHIMA VISION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2019-01-01
502 2019-01-01
502 2018-08-01 DORIS GLOVER
502 2017-08-01
502 2016-08-01 DORIS GLOVER
502 2015-08-01 DORIS GLOVER
502 2014-08-01 DORIS GLOVER
502 2013-08-01 DANNY HOLLIS
502 2012-08-01 DANNY HOLLIS
502 2011-08-01 DANNY HOLLIS
502 2010-08-01 DANNY HOLLIS
502 2009-08-01 DANNY HOLLIS
502 2008-08-01 DANNY HOLLIS
502 2007-08-01 DANNY HOLLIS
502 2006-12-01 DANNY HOLLIS
502 2005-12-01 DANNY HOLLIS
502 2004-12-01 DANNY HOLLIS

Plan Statistics for TB KAWASHIMA VISION PLAN

401k plan membership statisitcs for TB KAWASHIMA VISION PLAN

Measure Date Value
2019: TB KAWASHIMA VISION PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 103
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 86
Number of retired or separated participants receiving benefits 2019-01-01 1
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 87
2018: TB KAWASHIMA VISION PLAN 2018 401k membership
Total participants, beginning-of-year 2018-08-01 101
Total number of active participants reported on line 7a of the Form 5500 2018-08-01 101
Number of retired or separated participants receiving benefits 2018-08-01 0
Number of other retired or separated participants entitled to future benefits 2018-08-01 0
Total of all active and inactive participants 2018-08-01 101
2017: TB KAWASHIMA VISION PLAN 2017 401k membership
Total participants, beginning-of-year 2017-08-01 120
Total number of active participants reported on line 7a of the Form 5500 2017-08-01 101
Number of retired or separated participants receiving benefits 2017-08-01 0
Number of other retired or separated participants entitled to future benefits 2017-08-01 0
Total of all active and inactive participants 2017-08-01 101
2016: TB KAWASHIMA VISION PLAN 2016 401k membership
Total participants, beginning-of-year 2016-08-01 131
Total number of active participants reported on line 7a of the Form 5500 2016-08-01 120
Number of retired or separated participants receiving benefits 2016-08-01 0
Number of other retired or separated participants entitled to future benefits 2016-08-01 0
Total of all active and inactive participants 2016-08-01 120
2015: TB KAWASHIMA VISION PLAN 2015 401k membership
Total participants, beginning-of-year 2015-08-01 131
Total number of active participants reported on line 7a of the Form 5500 2015-08-01 131
Number of retired or separated participants receiving benefits 2015-08-01 0
Number of other retired or separated participants entitled to future benefits 2015-08-01 0
Total of all active and inactive participants 2015-08-01 131
2014: TB KAWASHIMA VISION PLAN 2014 401k membership
Total participants, beginning-of-year 2014-08-01 169
Total number of active participants reported on line 7a of the Form 5500 2014-08-01 162
Number of retired or separated participants receiving benefits 2014-08-01 0
Number of other retired or separated participants entitled to future benefits 2014-08-01 0
Total of all active and inactive participants 2014-08-01 162
2013: TB KAWASHIMA VISION PLAN 2013 401k membership
Total participants, beginning-of-year 2013-08-01 169
Total number of active participants reported on line 7a of the Form 5500 2013-08-01 169
Number of retired or separated participants receiving benefits 2013-08-01 0
Number of other retired or separated participants entitled to future benefits 2013-08-01 0
Total of all active and inactive participants 2013-08-01 169
2012: TB KAWASHIMA VISION PLAN 2012 401k membership
Total participants, beginning-of-year 2012-08-01 258
Total number of active participants reported on line 7a of the Form 5500 2012-08-01 273
Number of retired or separated participants receiving benefits 2012-08-01 0
Number of other retired or separated participants entitled to future benefits 2012-08-01 0
Total of all active and inactive participants 2012-08-01 273
2011: TB KAWASHIMA VISION PLAN 2011 401k membership
Total participants, beginning-of-year 2011-08-01 145
Total number of active participants reported on line 7a of the Form 5500 2011-08-01 258
Number of retired or separated participants receiving benefits 2011-08-01 0
Number of other retired or separated participants entitled to future benefits 2011-08-01 0
Total of all active and inactive participants 2011-08-01 258
2010: TB KAWASHIMA VISION PLAN 2010 401k membership
Total participants, beginning-of-year 2010-08-01 121
Total number of active participants reported on line 7a of the Form 5500 2010-08-01 145
Number of retired or separated participants receiving benefits 2010-08-01 0
Number of other retired or separated participants entitled to future benefits 2010-08-01 0
Total of all active and inactive participants 2010-08-01 145
2009: TB KAWASHIMA VISION PLAN 2009 401k membership
Total participants, beginning-of-year 2009-08-01 107
Total number of active participants reported on line 7a of the Form 5500 2009-08-01 121
Number of retired or separated participants receiving benefits 2009-08-01 0
Number of other retired or separated participants entitled to future benefits 2009-08-01 0
Total of all active and inactive participants 2009-08-01 121
2008: TB KAWASHIMA VISION PLAN 2008 401k membership
Total participants, beginning-of-year 2008-08-01 165
Total number of active participants reported on line 7a of the Form 5500 2008-08-01 107
Number of retired or separated participants receiving benefits 2008-08-01 0
Number of other retired or separated participants entitled to future benefits 2008-08-01 0
Total of all active and inactive participants 2008-08-01 107
2007: TB KAWASHIMA VISION PLAN 2007 401k membership
Total participants, beginning-of-year 2007-08-01 167
Total number of active participants reported on line 7a of the Form 5500 2007-08-01 165
Number of retired or separated participants receiving benefits 2007-08-01 0
Number of other retired or separated participants entitled to future benefits 2007-08-01 0
Total of all active and inactive participants 2007-08-01 165
2006: TB KAWASHIMA VISION PLAN 2006 401k membership
Total participants, beginning-of-year 2006-12-01 146
Total number of active participants reported on line 7a of the Form 5500 2006-12-01 146
Number of retired or separated participants receiving benefits 2006-12-01 0
Number of other retired or separated participants entitled to future benefits 2006-12-01 0
Total of all active and inactive participants 2006-12-01 146
2005: TB KAWASHIMA VISION PLAN 2005 401k membership
Total participants, beginning-of-year 2005-12-01 146
Total number of active participants reported on line 7a of the Form 5500 2005-12-01 146
Number of retired or separated participants receiving benefits 2005-12-01 0
Number of other retired or separated participants entitled to future benefits 2005-12-01 0
Total of all active and inactive participants 2005-12-01 146
2004: TB KAWASHIMA VISION PLAN 2004 401k membership
Total participants, beginning-of-year 2004-12-01 150
Total number of active participants reported on line 7a of the Form 5500 2004-12-01 146
Number of retired or separated participants receiving benefits 2004-12-01 0
Number of other retired or separated participants entitled to future benefits 2004-12-01 0
Total of all active and inactive participants 2004-12-01 146

Measure	Date	Value
2019: TB KAWASHIMA VISION PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	103
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	86
Number of retired or separated participants receiving benefits	2019-01-01	1
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	87
2018: TB KAWASHIMA VISION PLAN 2018 401k membership
Total participants, beginning-of-year	2018-08-01	101
Total number of active participants reported on line 7a of the Form 5500	2018-08-01	101
Number of retired or separated participants receiving benefits	2018-08-01	0
Number of other retired or separated participants entitled to future benefits	2018-08-01	0
Total of all active and inactive participants	2018-08-01	101
2017: TB KAWASHIMA VISION PLAN 2017 401k membership
Total participants, beginning-of-year	2017-08-01	120
Total number of active participants reported on line 7a of the Form 5500	2017-08-01	101
Number of retired or separated participants receiving benefits	2017-08-01	0
Number of other retired or separated participants entitled to future benefits	2017-08-01	0
Total of all active and inactive participants	2017-08-01	101
2016: TB KAWASHIMA VISION PLAN 2016 401k membership
Total participants, beginning-of-year	2016-08-01	131
Total number of active participants reported on line 7a of the Form 5500	2016-08-01	120
Number of retired or separated participants receiving benefits	2016-08-01	0
Number of other retired or separated participants entitled to future benefits	2016-08-01	0
Total of all active and inactive participants	2016-08-01	120
2015: TB KAWASHIMA VISION PLAN 2015 401k membership
Total participants, beginning-of-year	2015-08-01	131
Total number of active participants reported on line 7a of the Form 5500	2015-08-01	131
Number of retired or separated participants receiving benefits	2015-08-01	0
Number of other retired or separated participants entitled to future benefits	2015-08-01	0
Total of all active and inactive participants	2015-08-01	131
2014: TB KAWASHIMA VISION PLAN 2014 401k membership
Total participants, beginning-of-year	2014-08-01	169
Total number of active participants reported on line 7a of the Form 5500	2014-08-01	162
Number of retired or separated participants receiving benefits	2014-08-01	0
Number of other retired or separated participants entitled to future benefits	2014-08-01	0
Total of all active and inactive participants	2014-08-01	162
2013: TB KAWASHIMA VISION PLAN 2013 401k membership
Total participants, beginning-of-year	2013-08-01	169
Total number of active participants reported on line 7a of the Form 5500	2013-08-01	169
Number of retired or separated participants receiving benefits	2013-08-01	0
Number of other retired or separated participants entitled to future benefits	2013-08-01	0
Total of all active and inactive participants	2013-08-01	169
2012: TB KAWASHIMA VISION PLAN 2012 401k membership
Total participants, beginning-of-year	2012-08-01	258
Total number of active participants reported on line 7a of the Form 5500	2012-08-01	273
Number of retired or separated participants receiving benefits	2012-08-01	0
Number of other retired or separated participants entitled to future benefits	2012-08-01	0
Total of all active and inactive participants	2012-08-01	273
2011: TB KAWASHIMA VISION PLAN 2011 401k membership
Total participants, beginning-of-year	2011-08-01	145
Total number of active participants reported on line 7a of the Form 5500	2011-08-01	258
Number of retired or separated participants receiving benefits	2011-08-01	0
Number of other retired or separated participants entitled to future benefits	2011-08-01	0
Total of all active and inactive participants	2011-08-01	258
2010: TB KAWASHIMA VISION PLAN 2010 401k membership
Total participants, beginning-of-year	2010-08-01	121
Total number of active participants reported on line 7a of the Form 5500	2010-08-01	145
Number of retired or separated participants receiving benefits	2010-08-01	0
Number of other retired or separated participants entitled to future benefits	2010-08-01	0
Total of all active and inactive participants	2010-08-01	145
2009: TB KAWASHIMA VISION PLAN 2009 401k membership
Total participants, beginning-of-year	2009-08-01	107
Total number of active participants reported on line 7a of the Form 5500	2009-08-01	121
Number of retired or separated participants receiving benefits	2009-08-01	0
Number of other retired or separated participants entitled to future benefits	2009-08-01	0
Total of all active and inactive participants	2009-08-01	121
2008: TB KAWASHIMA VISION PLAN 2008 401k membership
Total participants, beginning-of-year	2008-08-01	165
Total number of active participants reported on line 7a of the Form 5500	2008-08-01	107
Number of retired or separated participants receiving benefits	2008-08-01	0
Number of other retired or separated participants entitled to future benefits	2008-08-01	0
Total of all active and inactive participants	2008-08-01	107
2007: TB KAWASHIMA VISION PLAN 2007 401k membership
Total participants, beginning-of-year	2007-08-01	167
Total number of active participants reported on line 7a of the Form 5500	2007-08-01	165
Number of retired or separated participants receiving benefits	2007-08-01	0
Number of other retired or separated participants entitled to future benefits	2007-08-01	0
Total of all active and inactive participants	2007-08-01	165
2006: TB KAWASHIMA VISION PLAN 2006 401k membership
Total participants, beginning-of-year	2006-12-01	146
Total number of active participants reported on line 7a of the Form 5500	2006-12-01	146
Number of retired or separated participants receiving benefits	2006-12-01	0
Number of other retired or separated participants entitled to future benefits	2006-12-01	0
Total of all active and inactive participants	2006-12-01	146
2005: TB KAWASHIMA VISION PLAN 2005 401k membership
Total participants, beginning-of-year	2005-12-01	146
Total number of active participants reported on line 7a of the Form 5500	2005-12-01	146
Number of retired or separated participants receiving benefits	2005-12-01	0
Number of other retired or separated participants entitled to future benefits	2005-12-01	0
Total of all active and inactive participants	2005-12-01	146
2004: TB KAWASHIMA VISION PLAN 2004 401k membership
Total participants, beginning-of-year	2004-12-01	150
Total number of active participants reported on line 7a of the Form 5500	2004-12-01	146
Number of retired or separated participants receiving benefits	2004-12-01	0
Number of other retired or separated participants entitled to future benefits	2004-12-01	0
Total of all active and inactive participants	2004-12-01	146

Form 5500 Responses for TB KAWASHIMA VISION PLAN

2019: TB KAWASHIMA VISION PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: TB KAWASHIMA VISION PLAN 2018 form 5500 responses
2018-08-01	Type of plan entity	Single employer plan
2018-08-01	Submission has been amended	No
2018-08-01	This submission is the final filing	No
2018-08-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2018-08-01	Plan is a collectively bargained plan	No
2018-08-01	Plan funding arrangement – Insurance	Yes
2018-08-01	Plan benefit arrangement – Insurance	Yes
2017: TB KAWASHIMA VISION PLAN 2017 form 5500 responses
2017-08-01	Type of plan entity	Single employer plan
2017-08-01	Submission has been amended	No
2017-08-01	This submission is the final filing	No
2017-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-08-01	Plan is a collectively bargained plan	No
2017-08-01	Plan funding arrangement – Insurance	Yes
2017-08-01	Plan benefit arrangement – Insurance	Yes
2016: TB KAWASHIMA VISION PLAN 2016 form 5500 responses
2016-08-01	Type of plan entity	Single employer plan
2016-08-01	Submission has been amended	No
2016-08-01	This submission is the final filing	No
2016-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-08-01	Plan is a collectively bargained plan	No
2016-08-01	Plan funding arrangement – Insurance	Yes
2016-08-01	Plan benefit arrangement – Insurance	Yes
2015: TB KAWASHIMA VISION PLAN 2015 form 5500 responses
2015-08-01	Type of plan entity	Single employer plan
2015-08-01	Submission has been amended	No
2015-08-01	This submission is the final filing	No
2015-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-08-01	Plan is a collectively bargained plan	No
2015-08-01	Plan funding arrangement – Insurance	Yes
2015-08-01	Plan benefit arrangement – Insurance	Yes
2014: TB KAWASHIMA VISION PLAN 2014 form 5500 responses
2014-08-01	Type of plan entity	Single employer plan
2014-08-01	Submission has been amended	No
2014-08-01	This submission is the final filing	No
2014-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-08-01	Plan is a collectively bargained plan	No
2014-08-01	Plan funding arrangement – Insurance	Yes
2014-08-01	Plan benefit arrangement – Insurance	Yes
2013: TB KAWASHIMA VISION PLAN 2013 form 5500 responses
2013-08-01	Type of plan entity	Single employer plan
2013-08-01	Submission has been amended	No
2013-08-01	This submission is the final filing	No
2013-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-08-01	Plan is a collectively bargained plan	No
2013-08-01	Plan funding arrangement – Insurance	Yes
2013-08-01	Plan benefit arrangement – Insurance	Yes
2012: TB KAWASHIMA VISION PLAN 2012 form 5500 responses
2012-08-01	Type of plan entity	Single employer plan
2012-08-01	Submission has been amended	No
2012-08-01	This submission is the final filing	No
2012-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-08-01	Plan is a collectively bargained plan	No
2012-08-01	Plan funding arrangement – Insurance	Yes
2012-08-01	Plan benefit arrangement – Insurance	Yes
2011: TB KAWASHIMA VISION PLAN 2011 form 5500 responses
2011-08-01	Type of plan entity	Single employer plan
2011-08-01	Submission has been amended	No
2011-08-01	This submission is the final filing	No
2011-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-08-01	Plan is a collectively bargained plan	No
2011-08-01	Plan funding arrangement – Insurance	Yes
2011-08-01	Plan benefit arrangement – Insurance	Yes
2010: TB KAWASHIMA VISION PLAN 2010 form 5500 responses
2010-08-01	Type of plan entity	Single employer plan
2010-08-01	Submission has been amended	No
2010-08-01	This submission is the final filing	No
2010-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-08-01	Plan is a collectively bargained plan	No
2010-08-01	Plan funding arrangement – Insurance	Yes
2010-08-01	Plan benefit arrangement – Insurance	Yes
2009: TB KAWASHIMA VISION PLAN 2009 form 5500 responses
2009-08-01	Type of plan entity	Single employer plan
2009-08-01	Submission has been amended	No
2009-08-01	This submission is the final filing	No
2009-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-08-01	Plan is a collectively bargained plan	No
2009-08-01	Plan funding arrangement – Insurance	Yes
2009-08-01	Plan benefit arrangement – Insurance	Yes
2008: TB KAWASHIMA VISION PLAN 2008 form 5500 responses
2008-08-01	Type of plan entity	Single employer plan
2008-08-01	Submission has been amended	No
2008-08-01	This submission is the final filing	No
2008-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-08-01	Plan is a collectively bargained plan	No
2008-08-01	Plan funding arrangement – Insurance	Yes
2008-08-01	Plan benefit arrangement – Insurance	Yes
2007: TB KAWASHIMA VISION PLAN 2007 form 5500 responses
2007-08-01	Type of plan entity	Single employer plan
2007-08-01	Submission has been amended	Yes
2007-08-01	This submission is the final filing	No
2007-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2007-08-01	Plan is a collectively bargained plan	No
2007-08-01	Plan funding arrangement – Insurance	Yes
2007-08-01	Plan benefit arrangement – Insurance	Yes
2006: TB KAWASHIMA VISION PLAN 2006 form 5500 responses
2006-12-01	Type of plan entity	Single employer plan
2006-12-01	Submission has been amended	No
2006-12-01	This submission is the final filing	No
2006-12-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2006-12-01	Plan is a collectively bargained plan	No
2006-12-01	Plan funding arrangement – Insurance	Yes
2006-12-01	Plan benefit arrangement – Insurance	Yes
2005: TB KAWASHIMA VISION PLAN 2005 form 5500 responses
2005-12-01	Type of plan entity	Single employer plan
2005-12-01	Submission has been amended	No
2005-12-01	This submission is the final filing	No
2005-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2005-12-01	Plan is a collectively bargained plan	No
2005-12-01	Plan funding arrangement – Insurance	Yes
2005-12-01	Plan benefit arrangement – Insurance	Yes
2004: TB KAWASHIMA VISION PLAN 2004 form 5500 responses
2004-12-01	Type of plan entity	Single employer plan
2004-12-01	First time form 5500 has been submitted	Yes
2004-12-01	Submission has been amended	No
2004-12-01	This submission is the final filing	No
2004-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2004-12-01	Plan is a collectively bargained plan	No
2004-12-01	Plan funding arrangement – Insurance	Yes
2004-12-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

TBKW814

Policy instance

Insurance contract or identification number	TBKW814
Number of Individuals Covered	86
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $988
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 $8,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $988
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

TBKW814

Policy instance

Insurance contract or identification number	TBKW814
Number of Individuals Covered	101
Insurance policy start date	2018-08-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $532
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 $4,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $532
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

TBKW814

Policy instance

Insurance contract or identification number	TBKW814
Number of Individuals Covered	101
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,267
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 $11,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	TB KAWASHIMA USA INC.
Employer identification number (EIN):	043679418
NAIC Classification:	314000
NAIC Description:	Textile Product Mills