401k Plan data: DORNERWORKS WELFARE BENEFIT PLAN plan

DORNERWORKS WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	DORNERWORKS WELFARE BENEFIT PLAN
Plan identification number	501

DORNERWORKS WELFARE BENEFIT 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

DORNERWORKS, LTD. has sponsored the creation of one or more 401k plans.

Company Name: DORNERWORKS, LTD.

Employer identification number (EIN): 383534524

NAIC Classification: 541519
NAIC Description: Other Computer Related Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DORNERWORKS WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-07-01 SARA PARMETER 2024-11-25
501 2022-07-01 SARA PARMETER 2024-01-12

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-07-01	SARA PARMETER	2024-11-25
501	2022-07-01	SARA PARMETER	2024-01-12

Form 5500 Responses for DORNERWORKS WELFARE BENEFIT PLAN

2023: DORNERWORKS WELFARE BENEFIT PLAN 2023 form 5500 responses
2023-07-01	Type of plan entity	Single employer plan
2023-07-01	Plan funding arrangement – Insurance	Yes
2023-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-07-01	Plan benefit arrangement – Insurance	Yes
2023-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: DORNERWORKS WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	First time form 5500 has been submitted	Yes
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

475151

Policy instance

Insurance contract or identification number	475151
Number of Individuals Covered	51
Insurance policy start date	2023-07-01
Insurance policy end date	2024-06-30
Total amount of commissions paid to insurance broker	USD $686
Total amount of fees paid to insurance company	USD $126
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,719
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

51828

Policy instance

Insurance contract or identification number	51828
Number of Individuals Covered	72
Insurance policy start date	2023-07-01
Insurance policy end date	2024-06-30
Total amount of commissions paid to insurance broker	USD $7,634
Total amount of fees paid to insurance company	USD $942
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $38,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

270548

Policy instance

Insurance contract or identification number	270548
Number of Individuals Covered	205
Insurance policy start date	2023-07-01
Insurance policy end date	2024-06-30
Total amount of commissions paid to insurance broker	USD $40,587
Total amount of fees paid to insurance company	USD $984
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

11478

Policy instance

Insurance contract or identification number	11478
Number of Individuals Covered	181
Insurance policy start date	2023-07-01
Insurance policy end date	2024-06-30
Total amount of commissions paid to insurance broker	USD $5,036
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

475151

Policy instance

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

Policy contract number

475149

Policy instance

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

270548

Policy instance

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Company Name:	DORNERWORKS, LTD.
Employer identification number (EIN):	383534524
NAIC Classification:	541519
NAIC Description:	Other Computer Related Services