401k Plan data: THE SHADOWFAX CORPORATION HEALTH INSURANCE BENEFIT plan

THE SHADOWFAX CORPORATION HEALTH INSURANCE BENEFIT 401k Plan overview

Plan Name	THE SHADOWFAX CORPORATION HEALTH INSURANCE BENEFIT
Plan identification number	502

THE SHADOWFAX CORPORATION HEALTH INSURANCE BENEFIT Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision Other welfare benefit cover

401k Sponsoring company profile

THE SHADOWFAX CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: THE SHADOWFAX CORPORATION

Employer identification number (EIN): 232368549

NAIC Classification: 624310
NAIC Description: Vocational Rehabilitation Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE SHADOWFAX CORPORATION HEALTH INSURANCE BENEFIT

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2009-03-01
502 2009-03-01 THERESA A. LINEBAUGH

Plan Statistics for THE SHADOWFAX CORPORATION HEALTH INSURANCE BENEFIT

401k plan membership statisitcs for THE SHADOWFAX CORPORATION HEALTH INSURANCE BENEFIT

Measure Date Value
2009: THE SHADOWFAX CORPORATION HEALTH INSURANCE BENEFIT 2009 401k membership
Total participants, beginning-of-year 2009-03-01 166
Total number of active participants reported on line 7a of the Form 5500 2009-03-01 0
Number of retired or separated participants receiving benefits 2009-03-01 0
Number of other retired or separated participants entitled to future benefits 2009-03-01 0
Total of all active and inactive participants 2009-03-01 0

Measure	Date	Value
2009: THE SHADOWFAX CORPORATION HEALTH INSURANCE BENEFIT 2009 401k membership
Total participants, beginning-of-year	2009-03-01	166
Total number of active participants reported on line 7a of the Form 5500	2009-03-01	0
Number of retired or separated participants receiving benefits	2009-03-01	0
Number of other retired or separated participants entitled to future benefits	2009-03-01	0
Total of all active and inactive participants	2009-03-01	0

Form 5500 Responses for THE SHADOWFAX CORPORATION HEALTH INSURANCE BENEFIT

2009: THE SHADOWFAX CORPORATION HEALTH INSURANCE BENEFIT 2009 form 5500 responses
2009-03-01	Type of plan entity	Single employer plan
2009-03-01	Submission has been amended	Yes
2009-03-01	This submission is the final filing	Yes
2009-03-01	Plan funding arrangement – Insurance	Yes
2009-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

1133

Policy instance

Insurance contract or identification number	1133
Number of Individuals Covered	0
Insurance policy start date	2009-03-01
Insurance policy end date	2010-02-28
Total amount of commissions paid to insurance broker	USD $616
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $616
Insurance broker organization code?	3
Insurance broker name	GLATFELTER AGENCY, INC.

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

02895960

Policy instance

Insurance contract or identification number	02895960
Number of Individuals Covered	0
Insurance policy start date	2009-03-01
Insurance policy end date	2010-02-28
Total amount of commissions paid to insurance broker	USD $4,003
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $133,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,003
Insurance broker organization code?	3
Insurance broker name	GLATFELTER AGENCY, INC.

KEYSTONE HEALTH PLAN WEST, INC (National Association of Insurance Commissioners NAIC id number: 95048 )

Policy contract number

02895960

Policy instance

Insurance contract or identification number	02895960
Number of Individuals Covered	0
Insurance policy start date	2009-03-01
Insurance policy end date	2010-02-28
Total amount of commissions paid to insurance broker	USD $21,591
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $685,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,591
Insurance broker organization code?	3
Insurance broker name	GLATFELTER AGENCY, INC.

DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 )

Policy contract number

2387

Policy instance

Insurance contract or identification number	2387
Number of Individuals Covered	0
Insurance policy start date	2009-03-01
Insurance policy end date	2010-02-28
Total amount of commissions paid to insurance broker	USD $1,996
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,996
Insurance broker organization code?	3
Insurance broker name	GLATFELTER AGENCY, INC.

TEACHERS PROTECTIVE MUTUAL LIFE INSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 69353 )

Policy contract number

GBQ-6040

Policy instance

Insurance contract or identification number	GBQ-6040
Number of Individuals Covered	0
Insurance policy start date	2009-03-01
Insurance policy end date	2010-02-28
Total amount of commissions paid to insurance broker	USD $10,152
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SUPPLEMENTAL GROUP ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $127,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,152
Insurance broker organization code?	3
Insurance broker name	GLATFELTER AGENCY, INC.

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Company Name:	THE SHADOWFAX CORPORATION
Employer identification number (EIN):	232368549
NAIC Classification:	624310
NAIC Description:	Vocational Rehabilitation Services