401k Plan data: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN plan

PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 401k Plan overview

Plan Name	PJ FITZPATRICK, INC. LIFE AND AD&D PLAN
Plan identification number	501

PJ FITZPATRICK, INC. LIFE AND AD&D PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Death benefits (include travel accident but not life insurance) 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

PJ FITZPATRICK, INC. has sponsored the creation of one or more 401k plans.

Company Name: PJ FITZPATRICK, INC.

Employer identification number (EIN): 270172384

NAIC Classification: 238900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PJ FITZPATRICK, INC. LIFE AND AD&D PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-01-01 SCOTT SCHMOYER
501 2015-01-01 SCOTT SCHMOYER
501 2015-01-01
501 2014-01-01 SCOTT SCHMOYER
501 2010-01-01 SCOTT SCHMOYER

Plan Statistics for PJ FITZPATRICK, INC. LIFE AND AD&D PLAN

401k plan membership statisitcs for PJ FITZPATRICK, INC. LIFE AND AD&D PLAN

Measure Date Value
2016: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 104
Total of all active and inactive participants 2016-01-01 0
2015: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 104
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 104
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 104
2014: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 101
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 104
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 104
2010: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 105
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 105

Measure	Date	Value
2016: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	104
Total of all active and inactive participants	2016-01-01	0
2015: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	104
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	104
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	104
2014: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	101
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	104
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	104
2010: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	105
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	105

Form 5500 Responses for PJ FITZPATRICK, INC. LIFE AND AD&D PLAN

2016: PJ FITZPATRICK, INC. LIFE AND AD&D 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	No
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 – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	Yes
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 – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	First time form 5500 has been submitted	Yes
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 – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: PJ FITZPATRICK, INC. LIFE AND AD&D PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	First time form 5500 has been submitted	Yes
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

0137281-001

Policy instance

Insurance contract or identification number	0137281-001
Number of Individuals Covered	105
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $544
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 AND DISMEMBERMENT
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 $5,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $544
Insurance broker organization code?	3

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Company Name:	PJ FITZPATRICK, INC.
Employer identification number (EIN):	270172384
NAIC Classification:	238900

Plan id#	Filing Submission Date	Name of Administrator
501	2016-01-01	SCOTT SCHMOYER
501	2015-01-01	SCOTT SCHMOYER
501	2015-01-01
501	2014-01-01	SCOTT SCHMOYER
501	2010-01-01	SCOTT SCHMOYER