401k Plan data: MOTHER LLC HEALTH AND WELFARE PLAN plan

MOTHER LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	MOTHER LLC HEALTH AND WELFARE PLAN
Plan identification number	501

MOTHER LLC HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

MOTHER LLC has sponsored the creation of one or more 401k plans.

Company Name: MOTHER LLC

Employer identification number (EIN): 273226907

NAIC Classification: 448190
NAIC Description: Other Clothing Stores

Additional information about MOTHER LLC

Jurisdiction of Incorporation: California Department of State

Incorporation Date:

Company Identification Number: 201401510489

More information about MOTHER LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MOTHER LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-12-01

Plan Statistics for MOTHER LLC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for MOTHER LLC HEALTH AND WELFARE PLAN

Measure Date Value
2022: MOTHER LLC HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-12-01 132
Total number of active participants reported on line 7a of the Form 5500 2022-12-01 178
Number of retired or separated participants receiving benefits 2022-12-01 1
Number of other retired or separated participants entitled to future benefits 2022-12-01 0
Total of all active and inactive participants 2022-12-01 179

Measure	Date	Value
2022: MOTHER LLC HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-12-01	132
Total number of active participants reported on line 7a of the Form 5500	2022-12-01	178
Number of retired or separated participants receiving benefits	2022-12-01	1
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	179

Form 5500 Responses for MOTHER LLC HEALTH AND WELFARE PLAN

2022: MOTHER LLC HEALTH AND WELFARE 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	Submission has been amended	No
2022-12-01	This submission is the final filing	No
2022-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-12-01	Plan is a collectively bargained plan	No
2022-12-01	Plan funding arrangement – Insurance	Yes
2022-12-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

L06834

Policy instance

Insurance contract or identification number	L06834
Number of Individuals Covered	176
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $5,066
Total amount of fees paid to insurance company	USD $2,025
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	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $96,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,066
Insurance broker organization code?	3
Amount paid for insurance broker fees	2025
Additional information about fees paid to insurance broker	OTHER FEES

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

L06834

Policy instance

Insurance contract or identification number	L06834
Number of Individuals Covered	104
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $48,903
Total amount of fees paid to insurance company	USD $19,546
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	Yes
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
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 $935,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,903
Insurance broker organization code?	3
Amount paid for insurance broker fees	19546
Additional information about fees paid to insurance broker	OTHER FEES

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Company Name:	MOTHER LLC
Employer identification number (EIN):	273226907
NAIC Classification:	448190
NAIC Description:	Other Clothing Stores

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	201401510489