401k Plan data: R&R CONTRACTING HEALTH PLAN plan

R&R CONTRACTING HEALTH PLAN 401k Plan overview

Plan Name	R&R CONTRACTING HEALTH PLAN
Plan identification number	501

R&R CONTRACTING HEALTH PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Other welfare benefit cover

401k Sponsoring company profile

R&R CONTRACTING has sponsored the creation of one or more 401k plans.

Company Name: R&R CONTRACTING

Employer identification number (EIN): 450407284

NAIC Classification: 237990
NAIC Description: Other Heavy and Civil Engineering Construction

Form 5500 Filing Information

Submission information for form 5500 for 401k plan R&R CONTRACTING HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-01-01 LINDA PIETRUSZEWSKI CHARITY BRAULT 2017-07-27
501 2015-01-01 LINDA PIETRUSZEWSKI CHARITY BRAULT 2016-07-25
501 2014-01-01 LINDA PIETRUSZEWSKI LINDA PIETRUSZEWSKI 2015-07-27

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2016-01-01	LINDA PIETRUSZEWSKI	CHARITY BRAULT	2017-07-27
501	2015-01-01	LINDA PIETRUSZEWSKI	CHARITY BRAULT	2016-07-25
501	2014-01-01	LINDA PIETRUSZEWSKI	LINDA PIETRUSZEWSKI	2015-07-27

Plan Statistics for R&R CONTRACTING HEALTH PLAN

401k plan membership statisitcs for R&R CONTRACTING HEALTH PLAN

Measure Date Value
2016: R&R CONTRACTING HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 94
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 76
Total of all active and inactive participants 2016-01-01 76
Total participants 2016-01-01 76
2015: R&R CONTRACTING HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 136
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 94
Total of all active and inactive participants 2015-01-01 94
Total participants 2015-01-01 94
2014: R&R CONTRACTING HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 136
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 136
Total of all active and inactive participants 2014-01-01 136
Total participants 2014-01-01 136

Measure	Date	Value
2016: R&R CONTRACTING HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	94
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	76
Total of all active and inactive participants	2016-01-01	76
Total participants	2016-01-01	76
2015: R&R CONTRACTING HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	136
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	94
Total of all active and inactive participants	2015-01-01	94
Total participants	2015-01-01	94
2014: R&R CONTRACTING HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	136
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	136
Total of all active and inactive participants	2014-01-01	136
Total participants	2014-01-01	136

Form 5500 Responses for R&R CONTRACTING HEALTH PLAN

2016: R&R CONTRACTING HEALTH PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	First time form 5500 has been submitted	Yes
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: R&R CONTRACTING HEALTH PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	First time form 5500 has been submitted	Yes
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: R&R CONTRACTING HEALTH PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	First time form 5500 has been submitted	Yes
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )

Policy contract number

69604

Policy instance

Insurance contract or identification number	69604
Number of Individuals Covered	94
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $6,840
Total amount of fees paid to insurance company	USD $90,655
Are there contracts with allocated funds for individual policies?	Yes
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	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
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,840
Insurance broker organization code?	3
Insurance broker name	THE INSURANCE CENTER INC

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

Policy contract number

G000AQWJ

Policy instance

Insurance contract or identification number	G000AQWJ
Number of Individuals Covered	114
Insurance policy start date	2014-10-01
Insurance policy end date	2015-10-01
Total amount of commissions paid to insurance broker	USD $621
Total amount of fees paid to insurance company	USD $320
Are there contracts with allocated funds for individual policies?	No
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
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 $6,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $621
Amount paid for insurance broker fees	320
Insurance broker organization code?	3
Insurance broker name	THE INSURANCE CENTER INC

BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )

Policy contract number

69604

Policy instance

Insurance contract or identification number	69604
Number of Individuals Covered	136
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $9,370
Are there contracts with allocated funds for individual policies?	No
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	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
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,370
Insurance broker name	THE INSURANCE CENTER INC

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

Policy contract number

G000AQWJ

Policy instance

Insurance contract or identification number	G000AQWJ
Number of Individuals Covered	55
Insurance policy start date	2013-10-01
Insurance policy end date	2014-10-01
Total amount of commissions paid to insurance broker	USD $2,820
Total amount of fees paid to insurance company	USD $111
Are there contracts with allocated funds for individual policies?	No
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
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 $18,797
Commission paid to Insurance Broker	USD $2,820
Amount paid for insurance broker fees	111
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THE INSURANCE CENTER INC

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

Policy contract number

G000AQWJ

Policy instance

Insurance contract or identification number	G000AQWJ
Number of Individuals Covered	102
Insurance policy start date	2013-10-01
Insurance policy end date	2014-10-01
Total amount of commissions paid to insurance broker	USD $72
Total amount of fees paid to insurance company	USD $65
Are there contracts with allocated funds for individual policies?	No
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
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 $7,824
Commission paid to Insurance Broker	USD $782
Amount paid for insurance broker fees	65
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THE INSURANCE CENTER INC

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

Policy contract number

G000AQWJ

Policy instance

Insurance contract or identification number	G000AQWJ
Number of Individuals Covered	50
Insurance policy start date	2013-10-01
Insurance policy end date	2014-10-01
Total amount of commissions paid to insurance broker	USD $3,058
Total amount of fees paid to insurance company	USD $100
Are there contracts with allocated funds for individual policies?	No
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	SHORT TERM DISABILITY
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 $20,387
Commission paid to Insurance Broker	USD $3,058
Amount paid for insurance broker fees	100
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THE INSURANCE COMPANY INC

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Company Name:	R&R CONTRACTING
Employer identification number (EIN):	450407284
NAIC Classification:	237990
NAIC Description:	Other Heavy and Civil Engineering Construction