401k Plan data: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN plan

SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 401k Plan overview

Plan Name	SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN
Plan identification number	501

SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN Benefits

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

401k Sponsoring company profile

SUTTER'S MILL SPECIALTIES, INC. has sponsored the creation of one or more 401k plans.

Company Name: SUTTER'S MILL SPECIALTIES, INC.

Employer identification number (EIN): 341654423

NAIC Classification: 541800

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2018-11-01
501 2018-08-01
501 2017-08-01
501 2016-08-01
501 2015-08-01

Plan Statistics for SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN

401k plan membership statisitcs for SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN

Measure Date Value
2018: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-11-01 136
Total number of active participants reported on line 7a of the Form 5500 2018-11-01 173
Number of retired or separated participants receiving benefits 2018-11-01 0
Number of other retired or separated participants entitled to future benefits 2018-11-01 0
Total of all active and inactive participants 2018-11-01 173
Total participants 2018-11-01 173
Total participants, beginning-of-year 2018-08-01 139
Total number of active participants reported on line 7a of the Form 5500 2018-08-01 136
Number of retired or separated participants receiving benefits 2018-08-01 0
Number of other retired or separated participants entitled to future benefits 2018-08-01 0
Total of all active and inactive participants 2018-08-01 136
2017: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-08-01 139
Total number of active participants reported on line 7a of the Form 5500 2017-08-01 139
Number of retired or separated participants receiving benefits 2017-08-01 0
Number of other retired or separated participants entitled to future benefits 2017-08-01 0
Total of all active and inactive participants 2017-08-01 139
2016: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-08-01 124
Total number of active participants reported on line 7a of the Form 5500 2016-08-01 139
Number of retired or separated participants receiving benefits 2016-08-01 0
Number of other retired or separated participants entitled to future benefits 2016-08-01 0
Total of all active and inactive participants 2016-08-01 139
2015: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-08-01 109
Total number of active participants reported on line 7a of the Form 5500 2015-08-01 124
Number of retired or separated participants receiving benefits 2015-08-01 0
Number of other retired or separated participants entitled to future benefits 2015-08-01 0
Total of all active and inactive participants 2015-08-01 124

Measure	Date	Value
2018: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-11-01	136
Total number of active participants reported on line 7a of the Form 5500	2018-11-01	173
Number of retired or separated participants receiving benefits	2018-11-01	0
Number of other retired or separated participants entitled to future benefits	2018-11-01	0
Total of all active and inactive participants	2018-11-01	173
Total participants	2018-11-01	173
Total participants, beginning-of-year	2018-08-01	139
Total number of active participants reported on line 7a of the Form 5500	2018-08-01	136
Number of retired or separated participants receiving benefits	2018-08-01	0
Number of other retired or separated participants entitled to future benefits	2018-08-01	0
Total of all active and inactive participants	2018-08-01	136
2017: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-08-01	139
Total number of active participants reported on line 7a of the Form 5500	2017-08-01	139
Number of retired or separated participants receiving benefits	2017-08-01	0
Number of other retired or separated participants entitled to future benefits	2017-08-01	0
Total of all active and inactive participants	2017-08-01	139
2016: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-08-01	124
Total number of active participants reported on line 7a of the Form 5500	2016-08-01	139
Number of retired or separated participants receiving benefits	2016-08-01	0
Number of other retired or separated participants entitled to future benefits	2016-08-01	0
Total of all active and inactive participants	2016-08-01	139
2015: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-08-01	109
Total number of active participants reported on line 7a of the Form 5500	2015-08-01	124
Number of retired or separated participants receiving benefits	2015-08-01	0
Number of other retired or separated participants entitled to future benefits	2015-08-01	0
Total of all active and inactive participants	2015-08-01	124

Form 5500 Responses for SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN

2018: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2018 form 5500 responses
2018-11-01	Type of plan entity	Single employer plan
2018-11-01	Submission has been amended	No
2018-11-01	This submission is the final filing	No
2018-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-11-01	Plan is a collectively bargained plan	No
2018-11-01	Plan funding arrangement – Insurance	Yes
2018-11-01	Plan benefit arrangement – Insurance	Yes
2018-08-01	Type of plan entity	Single employer plan
2018-08-01	Submission has been amended	No
2018-08-01	This submission is the final filing	No
2018-08-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2018-08-01	Plan is a collectively bargained plan	No
2018-08-01	Plan funding arrangement – Insurance	Yes
2018-08-01	Plan benefit arrangement – Insurance	Yes
2017: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2017 form 5500 responses
2017-08-01	Type of plan entity	Single employer plan
2017-08-01	Submission has been amended	No
2017-08-01	This submission is the final filing	No
2017-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-08-01	Plan is a collectively bargained plan	No
2017-08-01	Plan funding arrangement – Insurance	Yes
2017-08-01	Plan benefit arrangement – Insurance	Yes
2016: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2016 form 5500 responses
2016-08-01	Type of plan entity	Single employer plan
2016-08-01	Submission has been amended	No
2016-08-01	This submission is the final filing	No
2016-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-08-01	Plan is a collectively bargained plan	No
2016-08-01	Plan funding arrangement – Insurance	Yes
2016-08-01	Plan benefit arrangement – Insurance	Yes
2015: SUTTER'S MILL SPECIALTIES, INC. LIFE INSURANCE PLAN 2015 form 5500 responses
2015-08-01	Type of plan entity	Single employer plan
2015-08-01	First time form 5500 has been submitted	Yes
2015-08-01	Submission has been amended	No
2015-08-01	This submission is the final filing	No
2015-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-08-01	Plan is a collectively bargained plan	No
2015-08-01	Plan funding arrangement – Insurance	Yes
2015-08-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HEALTHIEST YOU (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

HY0847

Policy instance

Insurance contract or identification number	HY0847
Number of Individuals Covered	65
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $910
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	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	TELEMED & WELLNESS
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 $6,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $455
Amount paid for insurance broker fees	0

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGM609247

Policy instance

Insurance contract or identification number	SGM609247
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $548
Total amount of fees paid to insurance company	USD $196
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	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 $3,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $548
Amount paid for insurance broker fees	196
Additional information about fees paid to insurance broker	OVERRIDE

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

Policy contract number

00623679

Policy instance

Insurance contract or identification number	00623679
Number of Individuals Covered	79
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $16,190
Total amount of fees paid to insurance company	USD $6,172
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	Yes
Vision Insurance Welfare Benefit	Yes
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 $129,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	6172
Additional information about fees paid to insurance broker	SERVICE AND/OR GENERAL AGENT FEE

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

Policy contract number

GLUG0AAZY

Policy instance

Insurance contract or identification number	GLUG0AAZY
Number of Individuals Covered	136
Insurance policy start date	2018-08-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $119
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	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 $1,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $119
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GLUG0AAZY

Policy instance

Insurance contract or identification number	GLUG0AAZY
Number of Individuals Covered	139
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $507
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	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 $5,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

SUTTER'S MILL LASER ENGRAVING WELFARE BENEFIT PLAN [EIN = 261442433]

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Company Name:	SUTTER'S MILL SPECIALTIES, INC.
Employer identification number (EIN):	341654423
NAIC Classification:	541800