401k Plan data: ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN plan

ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 401k Plan overview

Plan Name	ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN
Plan identification number	002

ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

ARCHON WOODWORKS INC. has sponsored the creation of one or more 401k plans.

Company Name: ARCHON WOODWORKS INC.

Employer identification number (EIN): 201847966

NAIC Classification: 337000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2019-01-01 BRENDA HORNEFF 2019-12-22 BRENDA HORNEFF 2019-12-22
002 2018-01-01 BRENDA HORNEFF 2019-10-10 BRENDA HORNEFF 2019-10-10
002 2017-01-01
002 2017-01-01
002 2016-01-01 JOHN FRUHWIRTH 2017-05-26
002 2015-01-01 JOHN FRUHWIRTH 2016-08-15
002 2014-01-01 JOHN FRUHWIRTH 2015-07-30
002 2013-01-01 JOHN FRUHWIRTH 2014-07-22
002 2012-01-01 JOHN FRUEWIRTH 2013-09-19
002 2011-01-01 DONALD NELSON 2012-07-16
002 2010-01-01 DONALD NELSON 2011-07-18

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
002	2019-01-01	BRENDA HORNEFF	2019-12-22	BRENDA HORNEFF	2019-12-22
002	2018-01-01	BRENDA HORNEFF	2019-10-10	BRENDA HORNEFF	2019-10-10
002	2017-01-01
002	2017-01-01
002	2016-01-01	JOHN FRUHWIRTH	2017-05-26
002	2015-01-01	JOHN FRUHWIRTH	2016-08-15
002	2014-01-01	JOHN FRUHWIRTH	2015-07-30
002	2013-01-01	JOHN FRUHWIRTH	2014-07-22
002	2012-01-01	JOHN FRUEWIRTH	2013-09-19
002	2011-01-01	DONALD NELSON	2012-07-16
002	2010-01-01	DONALD NELSON	2011-07-18

Plan Statistics for ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN

401k plan membership statisitcs for ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN

Measure Date Value
2019: ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 124
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
Number of retired or separated participants receiving benefits 2019-01-01 0
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 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 0
Number of participants with account balances 2019-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2018: ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 152
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 105
Number of retired or separated participants receiving benefits 2018-01-01 14
Number of other retired or separated participants entitled to future benefits 2018-01-01 7
Total of all active and inactive participants 2018-01-01 126
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 126
Number of participants with account balances 2018-01-01 94
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 0
2017: ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 156
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 133
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 20
Total of all active and inactive participants 2017-01-01 153
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 153
Number of participants with account balances 2017-01-01 102
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0

Measure	Date	Value
2019: ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	124
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	0
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	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	0
Number of participants with account balances	2019-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2018: ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	152
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	105
Number of retired or separated participants receiving benefits	2018-01-01	14
Number of other retired or separated participants entitled to future benefits	2018-01-01	7
Total of all active and inactive participants	2018-01-01	126
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	126
Number of participants with account balances	2018-01-01	94
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0
2017: ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	156
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	133
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	20
Total of all active and inactive participants	2017-01-01	153
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	153
Number of participants with account balances	2017-01-01	102
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0

Financial Data on ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN

Measure	Date	Value
2019 : ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-05-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-05-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-05-31	$0
Total income from all sources (including contributions)	2019-05-31	$294,693
Total loss/gain on sale of assets	2019-05-31	$0
Total of all expenses incurred	2019-05-31	$2,933,842
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-05-31	$2,845,700
Expenses. Certain deemed distributions of participant loans	2019-05-31	$77,142
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-05-31	$11,559
Value of total assets at end of year	2019-05-31	$0
Value of total assets at beginning of year	2019-05-31	$2,639,149
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-05-31	$11,000
Total interest from all sources	2019-05-31	$1,670
Total dividends received (eg from common stock, registered investment company shares)	2019-05-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-05-31	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2019-05-31	$0
Administrative expenses professional fees incurred	2019-05-31	$11,000
Was this plan covered by a fidelity bond	2019-05-31	Yes
Value of fidelity bond cover	2019-05-31	$1,000,000
If this is an individual account plan, was there a blackout period	2019-05-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-05-31	$0
Were there any nonexempt tranactions with any party-in-interest	2019-05-31	No
Contributions received from participants	2019-05-31	$11,101
Participant contributions at end of year	2019-05-31	$0
Participant contributions at beginning of year	2019-05-31	$104,210
Participant contributions at end of year	2019-05-31	$0
Participant contributions at beginning of year	2019-05-31	$0
Assets. Other investments not covered elsewhere at end of year	2019-05-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2019-05-31	$18
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2019-05-31	$681
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-05-31	No
Value of net income/loss	2019-05-31	$-2,639,149
Value of net assets at end of year (total assets less liabilities)	2019-05-31	$0
Value of net assets at beginning of year (total assets less liabilities)	2019-05-31	$2,639,149
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-05-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-05-31	No
Were any leases to which the plan was party in default or uncollectible	2019-05-31	No
Value of interest in pooled separate accounts at end of year	2019-05-31	$0
Value of interest in pooled separate accounts at beginning of year	2019-05-31	$2,534,921
Interest on participant loans	2019-05-31	$1,670
Net investment gain/loss from pooled separate accounts	2019-05-31	$281,464
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-05-31	No
Was there a failure to transmit to the plan any participant contributions	2019-05-31	No
Has the plan failed to provide any benefit when due under the plan	2019-05-31	No
Contributions received in cash from employer	2019-05-31	$458
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-05-31	$2,845,019
Did the plan have assets held for investment	2019-05-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-05-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-05-31	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-05-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-05-31	Disclaimer
Accountancy firm name	2019-05-31	BERGANKDV
Accountancy firm EIN	2019-05-31	813053687
2018 : ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total income from all sources (including contributions)	2018-12-31	$-63,826
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$465,428
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$454,485
Expenses. Certain deemed distributions of participant loans	2018-12-31	$3,443
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$150,509
Value of total assets at end of year	2018-12-31	$2,639,149
Value of total assets at beginning of year	2018-12-31	$3,168,403
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$7,500
Total interest from all sources	2018-12-31	$4,500
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Administrative expenses professional fees incurred	2018-12-31	$7,500
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$119,420
Participant contributions at end of year	2018-12-31	$104,210
Participant contributions at beginning of year	2018-12-31	$102,339
Participant contributions at end of year	2018-12-31	$0
Participant contributions at beginning of year	2018-12-31	$65
Assets. Other investments not covered elsewhere at end of year	2018-12-31	$18
Assets. Other investments not covered elsewhere at beginning of year	2018-12-31	$18
Income. Received or receivable in cash from other sources (including rollovers)	2018-12-31	$26,318
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$-529,254
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$2,639,149
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$3,168,403
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Value of interest in pooled separate accounts at end of year	2018-12-31	$2,534,921
Value of interest in pooled separate accounts at beginning of year	2018-12-31	$3,065,981
Interest on participant loans	2018-12-31	$4,500
Net investment gain/loss from pooled separate accounts	2018-12-31	$-218,835
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Contributions received in cash from employer	2018-12-31	$4,771
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$454,485
Did the plan have assets held for investment	2018-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
2017 : ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total income from all sources (including contributions)	2017-12-31	$540,900
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$399,556
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$363,179
Expenses. Certain deemed distributions of participant loans	2017-12-31	$36,369
Value of total corrective distributions	2017-12-31	$8
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$143,449
Value of total assets at end of year	2017-12-31	$3,168,403
Value of total assets at beginning of year	2017-12-31	$3,027,059
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$0
Total interest from all sources	2017-12-31	$4,992
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$137,874
Participant contributions at end of year	2017-12-31	$102,339
Participant contributions at beginning of year	2017-12-31	$147,649
Participant contributions at end of year	2017-12-31	$-130
Participant contributions at beginning of year	2017-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2017-12-31	$18
Assets. Other investments not covered elsewhere at beginning of year	2017-12-31	$18
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$141,344
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$3,168,403
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$3,027,059
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Value of interest in pooled separate accounts at end of year	2017-12-31	$3,065,981
Value of interest in pooled separate accounts at beginning of year	2017-12-31	$2,879,392
Interest on participant loans	2017-12-31	$4,992
Net investment gain/loss from pooled separate accounts	2017-12-31	$392,459
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	No
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Contributions received in cash from employer	2017-12-31	$5,575
Employer contributions (assets) at end of year	2017-12-31	$195
Employer contributions (assets) at beginning of year	2017-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$363,179
Did the plan have assets held for investment	2017-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	HSMC ORIZON LLC
Accountancy firm EIN	2017-12-31	453576904

Form 5500 Responses for ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN

2019: ARCHON WOODWORKS INC. 401(K) PROFIT SHARING 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	Yes
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: ARCHON WOODWORKS INC. 401(K) PROFIT SHARING PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

99052

Policy instance

Insurance contract or identification number	99052
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $2,653
Total amount of fees paid to insurance company	USD $15,571
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?	Yes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,653
Insurance broker organization code?	3
Amount paid for insurance broker fees	15571
Additional information about fees paid to insurance broker	TPA COMPENSATION AUDITOR FEES

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

99052

Policy instance

Insurance contract or identification number	99052
Number of Individuals Covered	101
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,651
Total amount of fees paid to insurance company	USD $5,947
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?	Yes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,651
Insurance broker organization code?	3
Amount paid for insurance broker fees	5947
Additional information about fees paid to insurance broker	TPA COMPENSATION

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

99052

Policy instance

Insurance contract or identification number	99052
Number of Individuals Covered	104
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,273
Total amount of fees paid to insurance company	USD $5,886
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?	Yes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,273
Insurance broker organization code?	3
Amount paid for insurance broker fees	5886
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	BENEFIT PLANS, INC.

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Company Name:	ARCHON WOODWORKS INC.
Employer identification number (EIN):	201847966
NAIC Classification:	337000