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SHORT-TERM DISABILITY 401k Plan overview

Plan NameSHORT-TERM DISABILITY
Plan identification number 507

SHORT-TERM DISABILITY Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Life insurance
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

LAKE STATES TREE SERVICE, INC. has sponsored the creation of one or more 401k plans.

Company Name:LAKE STATES TREE SERVICE, INC.
Employer identification number (EIN):410810558
NAIC Classification:561730
NAIC Description:Landscaping Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SHORT-TERM DISABILITY

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5072019-09-01TINA LAVERDURE2021-01-14
5072019-09-01TINA LAVERDURE2021-02-23
5072017-09-01
5072016-09-01

Plan Statistics for SHORT-TERM DISABILITY

401k plan membership statisitcs for SHORT-TERM DISABILITY

Measure Date Value
2019: SHORT-TERM DISABILITY 2019 401k membership
Total participants, beginning-of-year2019-09-01105
Total number of active participants reported on line 7a of the Form 55002019-09-01113
Number of retired or separated participants receiving benefits2019-09-010
Number of other retired or separated participants entitled to future benefits2019-09-010
Total of all active and inactive participants2019-09-01113
Number of employers contributing to the scheme2019-09-010
2017: SHORT-TERM DISABILITY 2017 401k membership
Total participants, beginning-of-year2017-09-01106
Total number of active participants reported on line 7a of the Form 55002017-09-0196
Number of retired or separated participants receiving benefits2017-09-010
Number of other retired or separated participants entitled to future benefits2017-09-010
Total of all active and inactive participants2017-09-0196
2016: SHORT-TERM DISABILITY 2016 401k membership
Total participants, beginning-of-year2016-09-01100
Total number of active participants reported on line 7a of the Form 55002016-09-01106
Number of retired or separated participants receiving benefits2016-09-010
Number of other retired or separated participants entitled to future benefits2016-09-010
Total of all active and inactive participants2016-09-01106

Form 5500 Responses for SHORT-TERM DISABILITY

2019: SHORT-TERM DISABILITY 2019 form 5500 responses
2019-09-01Type of plan entitySingle employer plan
2019-09-01Submission has been amendedYes
2019-09-01Plan funding arrangement – InsuranceYes
2019-09-01Plan benefit arrangement – InsuranceYes
2017: SHORT-TERM DISABILITY 2017 form 5500 responses
2017-09-01Type of plan entitySingle employer plan
2017-09-01Plan funding arrangement – InsuranceYes
2017-09-01Plan benefit arrangement – InsuranceYes
2016: SHORT-TERM DISABILITY 2016 form 5500 responses
2016-09-01Type of plan entitySingle employer plan
2016-09-01First time form 5500 has been submittedYes
2016-09-01Plan funding arrangement – InsuranceYes
2016-09-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number552721
Policy instance 1
Insurance contract or identification number552721
Number of Individuals Covered113
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $5,206
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $52,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,206
Amount paid for insurance broker fees0
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160225
Policy instance 1
Insurance contract or identification number160225
Number of Individuals Covered96
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $1,575
Total amount of fees paid to insurance companyUSD $505
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,575
Amount paid for insurance broker fees179
Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.

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