401k Plan data: ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN plan

ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN 401k Plan overview

Plan Name	ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN
Plan identification number	502

ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Temporary disability (accident and sickness) Long-term disability cover

401k Sponsoring company profile

ERGOSAFE PRODUCTS LLC has sponsored the creation of one or more 401k plans.

Company Name: ERGOSAFE PRODUCTS LLC

Employer identification number (EIN): 200774268

NAIC Classification: 339900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2016-01-01 DAMONE BROWN DAMONE BROWN 2017-10-09
502 2015-01-01 PEGGY SOMMERKAMP PEGGY SOMMERKAMP 2016-08-29

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2016-01-01	DAMONE BROWN		DAMONE BROWN	2017-10-09
502	2015-01-01	PEGGY SOMMERKAMP		PEGGY SOMMERKAMP	2016-08-29

Plan Statistics for ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN

401k plan membership statisitcs for ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN

Measure Date Value
2016: ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 155
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 155
Total of all active and inactive participants 2016-01-01 155
Total participants 2016-01-01 155
2015: ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 132
Total of all active and inactive participants 2015-01-01 132
Total participants 2015-01-01 132

Measure	Date	Value
2016: ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	155
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	155
Total of all active and inactive participants	2016-01-01	155
Total participants	2016-01-01	155
2015: ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	132
Total of all active and inactive participants	2015-01-01	132
Total participants	2015-01-01	132

Form 5500 Responses for ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN

2016: ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: ERGOSAFE PRODUCTS, LLC. HEALTH INSURANCE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	First time form 5500 has been submitted	Yes
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

00144376

Policy instance

Insurance contract or identification number	00144376
Number of Individuals Covered	114
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $15,633
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $913,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,633
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CLJM LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010168319

Policy instance

Insurance contract or identification number	000010168319
Number of Individuals Covered	132
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,324
Total amount of fees paid to insurance company	USD $170
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,324
Amount paid for insurance broker fees	170
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CLJM LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010168320

Policy instance

Insurance contract or identification number	000010168320
Number of Individuals Covered	132
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,049
Total amount of fees paid to insurance company	USD $344
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $33,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,049
Amount paid for insurance broker fees	344
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CLJM LLC

DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )

Policy contract number

19501548

Policy instance

Insurance contract or identification number	19501548
Number of Individuals Covered	85
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,131
Total amount of fees paid to insurance company	USD $474
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,131
Amount paid for insurance broker fees	474
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CLJM, LLC DBA HUNTLEIGH MCGE

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Company Name:	ERGOSAFE PRODUCTS LLC
Employer identification number (EIN):	200774268
NAIC Classification:	339900