401k Plan data: TB PHILLY, INC. EMPLOYEE BENEFIT PLAN plan

TB PHILLY, INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	TB PHILLY, INC. EMPLOYEE BENEFIT PLAN
Plan identification number	501

TB PHILLY, INC. EMPLOYEE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision Long-term disability cover Other welfare benefit cover Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

TB PHILLY, INC. has sponsored the creation of one or more 401k plans.

Company Name: TB PHILLY, INC.

Employer identification number (EIN): 251757124

NAIC Classification: 423400

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TB PHILLY, INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-12-01 LISA TORRE 2024-06-05

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-12-01	LISA TORRE	2024-06-05

Plan Statistics for TB PHILLY, INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for TB PHILLY, INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: TB PHILLY, INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-12-01 100
Total number of active participants reported on line 7a of the Form 5500 2022-12-01 99
Number of retired or separated participants receiving benefits 2022-12-01 0
Number of other retired or separated participants entitled to future benefits 2022-12-01 0
Total of all active and inactive participants 2022-12-01 99
Number of employers contributing to the scheme 2022-12-01 0

Measure	Date	Value
2022: TB PHILLY, INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-12-01	100
Total number of active participants reported on line 7a of the Form 5500	2022-12-01	99
Number of retired or separated participants receiving benefits	2022-12-01	0
Number of other retired or separated participants entitled to future benefits	2022-12-01	0
Total of all active and inactive participants	2022-12-01	99
Number of employers contributing to the scheme	2022-12-01	0

Form 5500 Responses for TB PHILLY, INC. EMPLOYEE BENEFIT PLAN

2022: TB PHILLY, INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-12-01	Type of plan entity	Single employer plan
2022-12-01	First time form 5500 has been submitted	Yes
2022-12-01	Plan funding arrangement – Insurance	Yes
2022-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-12-01	Plan benefit arrangement – Insurance	Yes
2022-12-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

1124677

Policy instance

Insurance contract or identification number	1124677
Number of Individuals Covered	207
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $50,924
Total amount of fees paid to insurance company	USD $2,459
Health 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 $27,636
Amount paid for insurance broker fees	2459
Additional information about fees paid to insurance broker	OVERRIDE/NON-MONETARY COMPENSATION
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5580262

Policy instance

Insurance contract or identification number	5580262
Number of Individuals Covered	200
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $4,595
Total amount of fees paid to insurance company	USD $997
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,798
Amount paid for insurance broker fees	518
Additional information about fees paid to insurance broker	NON-MONETARY AND SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

99381191001

Policy instance

Insurance contract or identification number	99381191001
Number of Individuals Covered	213
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $609
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $435
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

144642

Policy instance

Insurance contract or identification number	144642
Number of Individuals Covered	11
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $9,620
Total amount of fees paid to insurance company	USD $2,568
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,149
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,713
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

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

Policy contract number

GLTD0BKTB

Policy instance

Insurance contract or identification number	GLTD0BKTB
Number of Individuals Covered	24
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $1,759
Total amount of fees paid to insurance company	USD $851
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,403
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

MAIN LINE AFFILIATES DBA FIRSTCALL (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Insurance contract or identification number	00
Number of Individuals Covered	99
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $2,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	TB PHILLY, INC.
Employer identification number (EIN):	251757124
NAIC Classification:	423400