401k Plan data: COLDQUANTA ANCILLARY BENEFITS PLAN plan

COLDQUANTA ANCILLARY BENEFITS PLAN 401k Plan overview

Plan Name	COLDQUANTA ANCILLARY BENEFITS PLAN
Plan identification number	503

COLDQUANTA ANCILLARY BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

COLDQUANTA INC 401(K) RETIREMENT PLAN has sponsored the creation of one or more 401k plans.

Company Name: COLDQUANTA INC 401(K) RETIREMENT PLAN

Employer identification number (EIN): 208401414

NAIC Classification: 541700

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COLDQUANTA ANCILLARY BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2022-06-01 KATHY CRAWFORD 2023-11-07

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
503	2022-06-01	KATHY CRAWFORD	2023-11-07

Plan Statistics for COLDQUANTA ANCILLARY BENEFITS PLAN

401k plan membership statisitcs for COLDQUANTA ANCILLARY BENEFITS PLAN

Measure Date Value
2022: COLDQUANTA ANCILLARY BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-06-01 157
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 187
Number of retired or separated participants receiving benefits 2022-06-01 187
Number of other retired or separated participants entitled to future benefits 2022-06-01 0
Total of all active and inactive participants 2022-06-01 374

Measure	Date	Value
2022: COLDQUANTA ANCILLARY BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-06-01	157
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	187
Number of retired or separated participants receiving benefits	2022-06-01	187
Number of other retired or separated participants entitled to future benefits	2022-06-01	0
Total of all active and inactive participants	2022-06-01	374

Form 5500 Responses for COLDQUANTA ANCILLARY BENEFITS PLAN

2022: COLDQUANTA ANCILLARY BENEFITS PLAN 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	First time form 5500 has been submitted	Yes
2022-06-01	Submission has been amended	No
2022-06-01	This submission is the final filing	No
2022-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-06-01	Plan is a collectively bargained plan	No
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GLTD0C4VY

Policy instance

Insurance contract or identification number	GLTD0C4VY
Number of Individuals Covered	199
Insurance policy start date	2023-06-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,383
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	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
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 $13,829
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

GLDG0C4VY

Policy instance

Insurance contract or identification number	GLDG0C4VY
Number of Individuals Covered	199
Insurance policy start date	2023-06-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $135
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	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
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 $1,353
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

GUG0C4VY

Policy instance

Insurance contract or identification number	GUG0C4VY
Number of Individuals Covered	199
Insurance policy start date	2023-06-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,566
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	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
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 $25,664
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

GVTL0C4VY

Policy instance

Insurance contract or identification number	GVTL0C4VY
Number of Individuals Covered	124
Insurance policy start date	2023-06-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $4,236
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	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT, VOLUNTARY
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 $28,241
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

GLTD0C4VY

Policy instance

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

Policy contract number

GLDG0C4VY

Policy instance

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

Policy contract number

GUG0C4VY

Policy instance

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

Policy contract number

GVTL0C4VY

Policy instance

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Company Name:	COLDQUANTA INC 401(K) RETIREMENT PLAN
Employer identification number (EIN):	208401414
NAIC Classification:	541700