401k Plan data: 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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
507 2023-11-01 BRANDY GRUBAUGH 2025-01-21
507 2022-11-01 BRANDY GRUBAUGH 2024-07-24
507 2021-11-01 CHERYL BUYNAK 2023-05-22
507 2020-11-01 CHERYL BUYNAK 2022-05-13
507 2019-11-01 FREDERICK DREIBHOLZ 2021-05-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
507	2023-11-01	BRANDY GRUBAUGH	2025-01-21
507	2022-11-01	BRANDY GRUBAUGH	2024-07-24
507	2021-11-01	CHERYL BUYNAK	2023-05-22
507	2020-11-01	CHERYL BUYNAK	2022-05-13
507	2019-11-01	FREDERICK DREIBHOLZ	2021-05-13

Plan Statistics for

401k plan membership statisitcs for

Measure Date Value
2023: 2023 401k membership
Total participants, beginning-of-year 2023-11-01 307
Total number of active participants reported on line 7a of the Form 5500 2023-11-01 159
Number of retired or separated participants receiving benefits 2023-11-01 0
Number of other retired or separated participants entitled to future benefits 2023-11-01 0
Total of all active and inactive participants 2023-11-01 159
Number of employers contributing to the scheme 2023-11-01 0
2022: 2022 401k membership
Total participants, beginning-of-year 2022-11-01 409
Total number of active participants reported on line 7a of the Form 5500 2022-11-01 410
Number of retired or separated participants receiving benefits 2022-11-01 3
Number of other retired or separated participants entitled to future benefits 2022-11-01 0
Total of all active and inactive participants 2022-11-01 413
Number of employers contributing to the scheme 2022-11-01 0
2021: 2021 401k membership
Total participants, beginning-of-year 2021-11-01 255
Total number of active participants reported on line 7a of the Form 5500 2021-11-01 358
Number of retired or separated participants receiving benefits 2021-11-01 2
Number of other retired or separated participants entitled to future benefits 2021-11-01 0
Total of all active and inactive participants 2021-11-01 360
Number of employers contributing to the scheme 2021-11-01 0
2020: 2020 401k membership
Total participants, beginning-of-year 2020-11-01 119
Total number of active participants reported on line 7a of the Form 5500 2020-11-01 102
Number of retired or separated participants receiving benefits 2020-11-01 0
Number of other retired or separated participants entitled to future benefits 2020-11-01 0
Total of all active and inactive participants 2020-11-01 102
Number of employers contributing to the scheme 2020-11-01 0
2019: 2019 401k membership
Total participants, beginning-of-year 2019-11-01 115
Total number of active participants reported on line 7a of the Form 5500 2019-11-01 97
Number of retired or separated participants receiving benefits 2019-11-01 3
Number of other retired or separated participants entitled to future benefits 2019-11-01 0
Total of all active and inactive participants 2019-11-01 100
Number of employers contributing to the scheme 2019-11-01 0

Measure	Date	Value
2023: 2023 401k membership
Total participants, beginning-of-year	2023-11-01	307
Total number of active participants reported on line 7a of the Form 5500	2023-11-01	159
Number of retired or separated participants receiving benefits	2023-11-01	0
Number of other retired or separated participants entitled to future benefits	2023-11-01	0
Total of all active and inactive participants	2023-11-01	159
Number of employers contributing to the scheme	2023-11-01	0
2022: 2022 401k membership
Total participants, beginning-of-year	2022-11-01	409
Total number of active participants reported on line 7a of the Form 5500	2022-11-01	410
Number of retired or separated participants receiving benefits	2022-11-01	3
Number of other retired or separated participants entitled to future benefits	2022-11-01	0
Total of all active and inactive participants	2022-11-01	413
Number of employers contributing to the scheme	2022-11-01	0
2021: 2021 401k membership
Total participants, beginning-of-year	2021-11-01	255
Total number of active participants reported on line 7a of the Form 5500	2021-11-01	358
Number of retired or separated participants receiving benefits	2021-11-01	2
Number of other retired or separated participants entitled to future benefits	2021-11-01	0
Total of all active and inactive participants	2021-11-01	360
Number of employers contributing to the scheme	2021-11-01	0
2020: 2020 401k membership
Total participants, beginning-of-year	2020-11-01	119
Total number of active participants reported on line 7a of the Form 5500	2020-11-01	102
Number of retired or separated participants receiving benefits	2020-11-01	0
Number of other retired or separated participants entitled to future benefits	2020-11-01	0
Total of all active and inactive participants	2020-11-01	102
Number of employers contributing to the scheme	2020-11-01	0
2019: 2019 401k membership
Total participants, beginning-of-year	2019-11-01	115
Total number of active participants reported on line 7a of the Form 5500	2019-11-01	97
Number of retired or separated participants receiving benefits	2019-11-01	3
Number of other retired or separated participants entitled to future benefits	2019-11-01	0
Total of all active and inactive participants	2019-11-01	100
Number of employers contributing to the scheme	2019-11-01	0

Form 5500 Responses for

2023: 2023 form 5500 responses
2023-11-01	Type of plan entity	Single employer plan
2023-11-01	Plan funding arrangement – Insurance	Yes
2023-11-01	Plan benefit arrangement – Insurance	Yes
2022: 2022 form 5500 responses
2022-11-01	Type of plan entity	Single employer plan
2022-11-01	Plan funding arrangement – Insurance	Yes
2022-11-01	Plan benefit arrangement – Insurance	Yes
2021: 2021 form 5500 responses
2021-11-01	Type of plan entity	Single employer plan
2021-11-01	Plan funding arrangement – Insurance	Yes
2021-11-01	Plan benefit arrangement – Insurance	Yes
2020: 2020 form 5500 responses
2020-11-01	Type of plan entity	Single employer plan
2020-11-01	Plan funding arrangement – Insurance	Yes
2020-11-01	Plan benefit arrangement – Insurance	Yes
2019: 2019 form 5500 responses
2019-11-01	Type of plan entity	Single employer plan
2019-11-01	Plan funding arrangement – Insurance	Yes
2019-11-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

916555

Policy instance

Insurance contract or identification number	916555
Number of Individuals Covered	25
Insurance policy start date	2023-11-01
Insurance policy end date	2024-10-31
Total amount of commissions paid to insurance broker	USD $1,245
Total amount of fees paid to insurance company	USD $141
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	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $8,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

916552

Policy instance

Insurance contract or identification number	916552
Number of Individuals Covered	315
Insurance policy start date	2023-11-01
Insurance policy end date	2024-10-31
Total amount of commissions paid to insurance broker	USD $6,981
Total amount of fees paid to insurance company	USD $775
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $43,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10399951001

Policy instance

Insurance contract or identification number	10399951001
Number of Individuals Covered	114
Insurance policy start date	2023-11-01
Insurance policy end date	2024-10-31
Total amount of commissions paid to insurance broker	USD $1,132
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

32569

Policy instance

Insurance contract or identification number	32569
Number of Individuals Covered	94
Insurance policy start date	2023-11-01
Insurance policy end date	2024-10-31
Total amount of commissions paid to insurance broker	USD $2,751
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,949
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

636946

Policy instance

Insurance contract or identification number	636946
Number of Individuals Covered	106
Insurance policy start date	2023-11-01
Insurance policy end date	2024-10-31
Total amount of commissions paid to insurance broker	USD $30,357
Total amount of fees paid to insurance company	USD $4,158
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $151,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

32569

Policy instance

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

Policy contract number

10399951001

Policy instance

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

Policy contract number

916552

Policy instance

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

916555

Policy instance

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

Policy contract number

636946

Policy instance

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

Policy contract number

309526

Policy instance

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

32569

Policy instance

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

30781-1151

Policy instance

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

Policy contract number

922450

Policy instance

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

32569

Policy instance

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

Policy contract number

702692

Policy instance

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

Policy contract number

702692

Policy instance

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

30781-1151

Policy instance

AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )

Policy contract number

10006882

Policy instance

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

27053

Policy instance

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