401k Plan data: FM SYLVAN, INC. WELFARE BENEFIT PLAN plan

FM SYLVAN, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	FM SYLVAN, INC. WELFARE BENEFIT PLAN
Plan identification number	501

FM SYLVAN, INC. WELFARE BENEFIT 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

F M SYLVAN, INC. has sponsored the creation of one or more 401k plans.

Company Name: F M SYLVAN, INC.

Employer identification number (EIN): 223841378

NAIC Classification: 332900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FM SYLVAN, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 ANDREA BLOOM 2024-08-19

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-01-01	ANDREA BLOOM	2024-08-19

Form 5500 Responses for FM SYLVAN, INC. WELFARE BENEFIT PLAN

2023: FM SYLVAN, INC. WELFARE BENEFIT PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	First time form 5500 has been submitted	Yes
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

156814

Policy instance

Insurance contract or identification number	156814
Number of Individuals Covered	238
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $66,698
Total amount of fees paid to insurance company	USD $1,020
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

1863

Policy instance

Insurance contract or identification number	1863
Number of Individuals Covered	253
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,928
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

97767331001

Policy instance

Insurance contract or identification number	97767331001
Number of Individuals Covered	246
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,449
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM0612466

Policy instance

Insurance contract or identification number	SGM0612466
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $12,914
Total amount of fees paid to insurance company	USD $0
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $114,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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Company Name:	F M SYLVAN, INC.
Employer identification number (EIN):	223841378
NAIC Classification:	332900