401k Plan data: FIVOS INC plan

FIVOS INC 401k Plan overview

Plan Name	FIVOS INC
Plan identification number	501

FIVOS INC 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) 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.

401k Sponsoring company profile

FIVOS INC. has sponsored the creation of one or more 401k plans.

Company Name: FIVOS INC.

Employer identification number (EIN): 451573625

NAIC Classification: 621510
NAIC Description: Medical and Diagnostic Laboratories

Additional information about FIVOS INC.

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division

Incorporation Date: 2007-01-04

Company Identification Number: 602682609

Legal Registered Office Address: 500 UNION ST STE 800

SEATTLE
United States of America (USA)
98101

More information about FIVOS INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIVOS INC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-01-01 JASON OLSON 2022-06-24
501 2021-01-01 JASON OLSON 2023-01-23

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-01-01	JASON OLSON	2022-06-24
501	2021-01-01	JASON OLSON	2023-01-23

Plan Statistics for FIVOS INC

401k plan membership statisitcs for FIVOS INC

Measure Date Value
2021: FIVOS INC 2021 401k membership
Total participants, beginning-of-year 2021-01-01 104
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 104
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 104
Number of employers contributing to the scheme 2021-01-01 0

Measure	Date	Value
2021: FIVOS INC 2021 401k membership
Total participants, beginning-of-year	2021-01-01	104
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	104
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	104
Number of employers contributing to the scheme	2021-01-01	0

Form 5500 Responses for FIVOS INC

2021: FIVOS INC 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30001990

Policy instance

Insurance contract or identification number	30001990
Number of Individuals Covered	61
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $712
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $712
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

ANTHEM HEALTH PLANS OF NEW HAMPSHIRE, INC. (National Association of Insurance Commissioners NAIC id number: 53759 )

Policy contract number

370402

Policy instance

Insurance contract or identification number	370402
Number of Individuals Covered	203
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,596
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $297,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,596
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

370402

Policy instance

Insurance contract or identification number	370402
Number of Individuals Covered	86
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,152
Total amount of fees paid to insurance company	USD $318
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
Welfare Benefit Premiums Paid to Carrier	USD $69,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,152
Amount paid for insurance broker fees	318
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

MATTHEW THORNTON HEALTH PLAN INC. (National Association of Insurance Commissioners NAIC id number: 95527 )

Policy contract number

370402

Policy instance

Insurance contract or identification number	370402
Number of Individuals Covered	42
Insurance policy start date	2021-01-01
Insurance policy end date	2021-01-31
Total amount of commissions paid to insurance broker	USD $1,114
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,114
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	FIVOS INC.
Employer identification number (EIN):	451573625
NAIC Classification:	621510
NAIC Description:	Medical and Diagnostic Laboratories

Jurisdiction of Incorporation:	Washington Secretary of State Corporations Division
Incorporation Date:	2007-01-04
Company Identification Number:	602682609
Legal Registered Office Address:	500 UNION ST STE 800 SEATTLE United States of America (USA) 98101