401k Plan data: OSI FURNITURE LLC SALARIED RETIREMENT PLAN plan

OSI FURNITURE LLC SALARIED RETIREMENT PLAN 401k Plan overview

Plan Name	OSI FURNITURE LLC SALARIED RETIREMENT PLAN
Plan identification number	002

OSI FURNITURE LLC SALARIED RETIREMENT PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
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.
Plan provides for automatic enrollment in plan that has employee contributions deducted from payroll.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Plan covering Self-Employed individuals.
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

OSI FURNITURE, LLC has sponsored the creation of one or more 401k plans.

Company Name: OSI FURNITURE, LLC

Employer identification number (EIN): 261405855

NAIC Classification: 332900

Additional information about OSI FURNITURE, LLC

Jurisdiction of Incorporation: Nevada Department of State

Incorporation Date: 2007-06-06

Company Identification Number: 20071052224

Legal Registered Office Address: 8960 SPANISH RIDGE AVE

LAS VEGAS
United States of America (USA)
89148

More information about OSI FURNITURE, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OSI FURNITURE LLC SALARIED RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2016-01-01 JEANETTE LIPECKI VYTAS AMBUTAS 2017-07-13
002 2015-01-01 JEANETTE LIPECKI VYTAS AMBUTAS 2016-06-17
002 2014-01-01 JEANETTE LIPECKI VYTAS AMBUTAS 2015-07-21
002 2013-01-01 JEANETTE LIPECKI VYTAS AMBUTAS 2014-07-01
002 2012-01-01 JEANETTE LIPECKI VYTAS AMBUTAS 2013-07-19
002 2011-01-01 JEANETTE LIPECKI 2012-07-17 VYTAS AMBUTAS 2012-07-17
002 2010-01-01 JEANETTE LIPECKI 2011-07-27 VYTAS AMBUTAS 2011-07-27
002 2009-01-01 VYTAS AMBUTAS VYTAS AMBUTAS 2010-09-09

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
002	2016-01-01	JEANETTE LIPECKI		VYTAS AMBUTAS	2017-07-13
002	2015-01-01	JEANETTE LIPECKI		VYTAS AMBUTAS	2016-06-17
002	2014-01-01	JEANETTE LIPECKI		VYTAS AMBUTAS	2015-07-21
002	2013-01-01	JEANETTE LIPECKI		VYTAS AMBUTAS	2014-07-01
002	2012-01-01	JEANETTE LIPECKI		VYTAS AMBUTAS	2013-07-19
002	2011-01-01	JEANETTE LIPECKI	2012-07-17	VYTAS AMBUTAS	2012-07-17
002	2010-01-01	JEANETTE LIPECKI	2011-07-27	VYTAS AMBUTAS	2011-07-27
002	2009-01-01	VYTAS AMBUTAS		VYTAS AMBUTAS	2010-09-09

Plan Statistics for OSI FURNITURE LLC SALARIED RETIREMENT PLAN

401k plan membership statisitcs for OSI FURNITURE LLC SALARIED RETIREMENT PLAN

Measure Date Value
2016: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 27
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 0
Number of participants with account balances 2016-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 29
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 0
Number of retired or separated participants receiving benefits 2015-01-01 2
Number of other retired or separated participants entitled to future benefits 2015-01-01 25
Total of all active and inactive participants 2015-01-01 27
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 27
Number of participants with account balances 2015-01-01 27
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 32
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 0
Number of retired or separated participants receiving benefits 2014-01-01 3
Number of other retired or separated participants entitled to future benefits 2014-01-01 24
Total of all active and inactive participants 2014-01-01 27
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 2
Total participants 2014-01-01 29
Number of participants with account balances 2014-01-01 29
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 40
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 0
Number of retired or separated participants receiving benefits 2013-01-01 4
Number of other retired or separated participants entitled to future benefits 2013-01-01 28
Total of all active and inactive participants 2013-01-01 32
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 32
Number of participants with account balances 2013-01-01 32
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 57
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 3
Number of retired or separated participants receiving benefits 2012-01-01 4
Number of other retired or separated participants entitled to future benefits 2012-01-01 33
Total of all active and inactive participants 2012-01-01 40
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 40
Number of participants with account balances 2012-01-01 40
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 10
2009: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 84
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 99
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 3
Total of all active and inactive participants 2009-01-01 102
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 102
Number of participants with account balances 2009-01-01 65
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 1

Measure	Date	Value
2016: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	27
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	0
Number of participants with account balances	2016-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	29
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	0
Number of retired or separated participants receiving benefits	2015-01-01	2
Number of other retired or separated participants entitled to future benefits	2015-01-01	25
Total of all active and inactive participants	2015-01-01	27
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	27
Number of participants with account balances	2015-01-01	27
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	32
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	0
Number of retired or separated participants receiving benefits	2014-01-01	3
Number of other retired or separated participants entitled to future benefits	2014-01-01	24
Total of all active and inactive participants	2014-01-01	27
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	2
Total participants	2014-01-01	29
Number of participants with account balances	2014-01-01	29
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	40
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	0
Number of retired or separated participants receiving benefits	2013-01-01	4
Number of other retired or separated participants entitled to future benefits	2013-01-01	28
Total of all active and inactive participants	2013-01-01	32
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	32
Number of participants with account balances	2013-01-01	32
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	57
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	3
Number of retired or separated participants receiving benefits	2012-01-01	4
Number of other retired or separated participants entitled to future benefits	2012-01-01	33
Total of all active and inactive participants	2012-01-01	40
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	40
Number of participants with account balances	2012-01-01	40
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	10
2009: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	84
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	99
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	3
Total of all active and inactive participants	2009-01-01	102
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	102
Number of participants with account balances	2009-01-01	65
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	1

Financial Data on OSI FURNITURE LLC SALARIED RETIREMENT PLAN

Measure	Date	Value
2016 : OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2016 401k financial data
Transfers to/from the plan	2016-12-31	$-2,018,943
Total income from all sources	2016-12-31	$51,876
Expenses. Total of all expenses incurred	2016-12-31	$35,641
Benefits paid (including direct rollovers)	2016-12-31	$35,481
Total plan assets at end of year	2016-12-31	$0
Total plan assets at beginning of year	2016-12-31	$2,002,708
Value of fidelity bond covering the plan	2016-12-31	$5,000,000
Total contributions received or receivable from participants	2016-12-31	$0
Contributions received from other sources (not participants or employers)	2016-12-31	$449
Other income received	2016-12-31	$51,427
Net income (gross income less expenses)	2016-12-31	$16,235
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$2,002,708
Total contributions received or receivable from employer(s)	2016-12-31	$0
Value of certain deemed distributions of participant loans	2016-12-31	$0
Value of corrective distributions	2016-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2016-12-31	$160
2015 : OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2015 401k financial data
Total income from all sources	2015-12-31	$38,572
Expenses. Total of all expenses incurred	2015-12-31	$76,633
Benefits paid (including direct rollovers)	2015-12-31	$76,273
Total plan assets at end of year	2015-12-31	$2,002,708
Total plan assets at beginning of year	2015-12-31	$2,040,769
Value of fidelity bond covering the plan	2015-12-31	$5,000,000
Total contributions received or receivable from participants	2015-12-31	$0
Expenses. Other expenses not covered elsewhere	2015-12-31	$0
Contributions received from other sources (not participants or employers)	2015-12-31	$0
Other income received	2015-12-31	$38,572
Net income (gross income less expenses)	2015-12-31	$-38,061
Net plan assets at end of year (total assets less liabilities)	2015-12-31	$2,002,708
Net plan assets at beginning of year (total assets less liabilities)	2015-12-31	$2,040,769
Total contributions received or receivable from employer(s)	2015-12-31	$0
Value of certain deemed distributions of participant loans	2015-12-31	$0
Value of corrective distributions	2015-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2015-12-31	$360
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
2014 : OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2014 401k financial data
Total income from all sources	2014-12-31	$104,818
Expenses. Total of all expenses incurred	2014-12-31	$296,900
Benefits paid (including direct rollovers)	2014-12-31	$296,340
Total plan assets at end of year	2014-12-31	$2,040,769
Total plan assets at beginning of year	2014-12-31	$2,232,851
Value of fidelity bond covering the plan	2014-12-31	$5,000,000
Total contributions received or receivable from participants	2014-12-31	$0
Expenses. Other expenses not covered elsewhere	2014-12-31	$0
Contributions received from other sources (not participants or employers)	2014-12-31	$0
Other income received	2014-12-31	$104,818
Net income (gross income less expenses)	2014-12-31	$-192,082
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$2,040,769
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$2,232,851
Total contributions received or receivable from employer(s)	2014-12-31	$0
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2014-12-31	$560
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
2013 : OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2013 401k financial data
Total income from all sources	2013-12-31	$266,520
Expenses. Total of all expenses incurred	2013-12-31	$1,057,306
Benefits paid (including direct rollovers)	2013-12-31	$1,056,406
Total plan assets at end of year	2013-12-31	$2,232,851
Total plan assets at beginning of year	2013-12-31	$3,023,637
Value of fidelity bond covering the plan	2013-12-31	$5,000,000
Total contributions received or receivable from participants	2013-12-31	$12,841
Expenses. Other expenses not covered elsewhere	2013-12-31	$300
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$253,679
Net income (gross income less expenses)	2013-12-31	$-790,786
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$2,232,851
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$3,023,637
Total contributions received or receivable from employer(s)	2013-12-31	$0
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2013-12-31	$600
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
2012 : OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2012 401k financial data
Total income from all sources	2012-12-31	$235,599
Expenses. Total of all expenses incurred	2012-12-31	$367,167
Benefits paid (including direct rollovers)	2012-12-31	$366,007
Total plan assets at end of year	2012-12-31	$3,023,637
Total plan assets at beginning of year	2012-12-31	$3,155,205
Value of fidelity bond covering the plan	2012-12-31	$5,000,000
Total contributions received or receivable from participants	2012-12-31	$36,902
Expenses. Other expenses not covered elsewhere	2012-12-31	$0
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$198,697
Net income (gross income less expenses)	2012-12-31	$-131,568
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$3,023,637
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$3,155,205
Total contributions received or receivable from employer(s)	2012-12-31	$0
Value of certain deemed distributions of participant loans	2012-12-31	$0
Value of corrective distributions	2012-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2012-12-31	$1,160
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
2009 : OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for OSI FURNITURE LLC SALARIED RETIREMENT PLAN

2016: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	Yes
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2009: OSI FURNITURE LLC SALARIED RETIREMENT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR 60343

Policy instance

Insurance contract or identification number	MR 60343
Number of Individuals Covered	27
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR 60343

Policy instance

Insurance contract or identification number	MR 60343
Number of Individuals Covered	29
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR 60343

Policy instance

Insurance contract or identification number	MR 60343
Number of Individuals Covered	32
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,094
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 $1,094
Insurance broker organization code?	1
Insurance broker name	FIRST HEARTLAND CAPITAL INC

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR 60343

Policy instance

Insurance contract or identification number	MR 60343
Number of Individuals Covered	40
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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

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Company Name:	OSI FURNITURE, LLC
Employer identification number (EIN):	261405855
NAIC Classification:	332900

Jurisdiction of Incorporation:	Nevada Department of State
Incorporation Date:	2007-06-06
Company Identification Number:	20071052224
Legal Registered Office Address:	8960 SPANISH RIDGE AVE LAS VEGAS United States of America (USA) 89148