401k Plan data: OBSIDIAN SOLUTIONS GROUP HEALTH AND WELFARE PLAN plan

OBSIDIAN SOLUTIONS GROUP HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	OBSIDIAN SOLUTIONS GROUP HEALTH AND WELFARE PLAN
Plan identification number	501

OBSIDIAN SOLUTIONS GROUP HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

OBSIDIAN SOLUTIONS GROUP LLC has sponsored the creation of one or more 401k plans.

Company Name: OBSIDIAN SOLUTIONS GROUP LLC

Employer identification number (EIN): 273709520

NAIC Classification: 541600

Additional information about OBSIDIAN SOLUTIONS GROUP LLC

Jurisdiction of Incorporation: Virginia Secretary of State

Incorporation Date: 2010-10-14

Company Identification Number: S341595

Legal Registered Office Address: 701 KENMORE AVENUE

FREDERICKSBURG
United States of America (USA)
22401

More information about OBSIDIAN SOLUTIONS GROUP LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OBSIDIAN SOLUTIONS GROUP HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-06-01 DINA L EVANS 2024-12-19
501 2022-06-01 DINA L EVANS 2023-12-07
501 2021-06-01 DINA L EVANS 2023-01-17
501 2020-06-01 DINA L EVANS 2021-11-01
501 2019-06-01 JAHI HENLEY 2020-12-17

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2023-06-01	DINA L EVANS	2024-12-19
501	2022-06-01	DINA L EVANS	2023-12-07
501	2021-06-01	DINA L EVANS	2023-01-17
501	2020-06-01	DINA L EVANS	2021-11-01
501	2019-06-01	JAHI HENLEY	2020-12-17

Form 5500 Responses for OBSIDIAN SOLUTIONS GROUP HEALTH AND WELFARE PLAN

2023: OBSIDIAN SOLUTIONS GROUP HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-06-01	Type of plan entity	Single employer plan
2023-06-01	Submission has been amended	No
2023-06-01	This submission is the final filing	No
2023-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-06-01	Plan is a collectively bargained plan	No
2023-06-01	Plan funding arrangement – Insurance	Yes
2023-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-06-01	Plan benefit arrangement – Insurance	Yes
2023-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: OBSIDIAN SOLUTIONS GROUP HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	Submission has been amended	No
2022-06-01	This submission is the final filing	No
2022-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-06-01	Plan is a collectively bargained plan	No
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2021: OBSIDIAN SOLUTIONS GROUP HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-06-01	Type of plan entity	Single employer plan
2021-06-01	Submission has been amended	No
2021-06-01	This submission is the final filing	No
2021-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-06-01	Plan is a collectively bargained plan	No
2021-06-01	Plan funding arrangement – Insurance	Yes
2021-06-01	Plan benefit arrangement – Insurance	Yes
2020: OBSIDIAN SOLUTIONS GROUP HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes
2019: OBSIDIAN SOLUTIONS GROUP HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	First time form 5500 has been submitted	Yes
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

0650272

Policy instance

Insurance contract or identification number	0650272
Number of Individuals Covered	124
Insurance policy start date	2023-06-01
Insurance policy end date	2024-05-31
Total amount of commissions paid to insurance broker	USD $12,919
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	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $130,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00650272

Policy instance

Insurance contract or identification number	00650272
Number of Individuals Covered	80
Insurance policy start date	2023-06-01
Insurance policy end date	2024-05-31
Total amount of commissions paid to insurance broker	USD $53,903
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	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $457,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

574792

Policy instance

Insurance contract or identification number	574792
Number of Individuals Covered	203
Insurance policy start date	2023-06-01
Insurance policy end date	2024-05-31
Total amount of commissions paid to insurance broker	USD $32,381
Total amount of fees paid to insurance company	USD $4,731
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
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 $236,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

914612

Policy instance

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

574792

Policy instance

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

914612

Policy instance

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

574792

Policy instance

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

914612

Policy instance

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

2994

Policy instance

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

574792

Policy instance

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

914612

Policy instance

MONUMENTAL LIFE (National Association of Insurance Commissioners NAIC id number: 66281 )

Policy contract number

0002414

Policy instance

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

Policy contract number

5318777

Policy instance

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Company Name:	OBSIDIAN SOLUTIONS GROUP LLC
Employer identification number (EIN):	273709520
NAIC Classification:	541600

Jurisdiction of Incorporation:	Virginia Secretary of State
Incorporation Date:	2010-10-14
Company Identification Number:	S341595
Legal Registered Office Address:	701 KENMORE AVENUE FREDERICKSBURG United States of America (USA) 22401