401k Plan data: SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN plan

SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN 401k Plan overview

Plan Name	SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN
Plan identification number	501

SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

SERVAAS LABORATORIES, INC. has sponsored the creation of one or more 401k plans.

Company Name: SERVAAS LABORATORIES, INC.

Employer identification number (EIN): 350910845

NAIC Classification: 325600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-04-01
501 2017-01-01 MATTHEW SELIG

Plan Statistics for SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN

401k plan membership statisitcs for SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN

Measure Date Value
2022: SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year 2022-04-01 100
Total number of active participants reported on line 7a of the Form 5500 2022-04-01 108
Total of all active and inactive participants 2022-04-01 108
2017: SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 17
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 25
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 25

Measure	Date	Value
2022: SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year	2022-04-01	100
Total number of active participants reported on line 7a of the Form 5500	2022-04-01	108
Total of all active and inactive participants	2022-04-01	108
2017: SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	17
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	25
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	25

Form 5500 Responses for SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN

2022: SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN 2022 form 5500 responses
2022-04-01	Type of plan entity	Single employer plan
2022-04-01	First time form 5500 has been submitted	Yes
2022-04-01	Submission has been amended	No
2022-04-01	This submission is the final filing	No
2022-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-04-01	Plan is a collectively bargained plan	No
2022-04-01	Plan funding arrangement – Insurance	Yes
2022-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-04-01	Plan benefit arrangement – Insurance	Yes
2022-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: SERVAAS LABORATORIES INC EMPLOYEE GROUP HEALTH PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	First time form 5500 has been submitted	Yes
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

00034649

Policy instance

Insurance contract or identification number	00034649
Number of Individuals Covered	108
Insurance policy start date	2022-04-01
Insurance policy end date	2023-03-31
Total amount of commissions paid to insurance broker	USD $25,313
Total amount of fees paid to insurance company	USD $3,354
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 AND DISMEMBERMENT ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY
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 $104,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,313
Amount paid for insurance broker fees	3354
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

30800-1256

Policy instance

Insurance contract or identification number	30800-1256
Number of Individuals Covered	16
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $310
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	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 $2,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $207
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	INSURANCE ASSOCIATES PLUS, INC.

DENTAL CARE PLUS, INC. (National Association of Insurance Commissioners NAIC id number: 96265 )

Policy contract number

02690801

Policy instance

Insurance contract or identification number	02690801
Number of Individuals Covered	48
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,161
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 $13,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,161
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	PAUL J. BECHTOLD

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Company Name:	SERVAAS LABORATORIES, INC.
Employer identification number (EIN):	350910845
NAIC Classification:	325600