401k Plan data: PENNENERGY RESOURCES MEDICAL AND VISION PLAN plan

PENNENERGY RESOURCES MEDICAL AND VISION PLAN 401k Plan overview

Plan Name	PENNENERGY RESOURCES MEDICAL AND VISION PLAN
Plan identification number	503

PENNENERGY RESOURCES MEDICAL AND VISION PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Vision

401k Sponsoring company profile

PENNENERGY RESOURCES, LLC has sponsored the creation of one or more 401k plans.

Company Name: PENNENERGY RESOURCES, LLC

Employer identification number (EIN): 452673440

NAIC Classification: 211130
NAIC Description: Natural Gas Extraction

Additional information about PENNENERGY RESOURCES, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 5003495

More information about PENNENERGY RESOURCES, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PENNENERGY RESOURCES MEDICAL AND VISION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2019-12-01
503 2019-12-01

Plan Statistics for PENNENERGY RESOURCES MEDICAL AND VISION PLAN

401k plan membership statisitcs for PENNENERGY RESOURCES MEDICAL AND VISION PLAN

Measure Date Value
2019: PENNENERGY RESOURCES MEDICAL AND VISION PLAN 2019 401k membership
Total participants, beginning-of-year 2019-12-01 112
Total number of active participants reported on line 7a of the Form 5500 2019-12-01 105
Number of retired or separated participants receiving benefits 2019-12-01 1
Number of other retired or separated participants entitled to future benefits 2019-12-01 0
Total of all active and inactive participants 2019-12-01 106

Measure	Date	Value
2019: PENNENERGY RESOURCES MEDICAL AND VISION PLAN 2019 401k membership
Total participants, beginning-of-year	2019-12-01	112
Total number of active participants reported on line 7a of the Form 5500	2019-12-01	105
Number of retired or separated participants receiving benefits	2019-12-01	1
Number of other retired or separated participants entitled to future benefits	2019-12-01	0
Total of all active and inactive participants	2019-12-01	106

Form 5500 Responses for PENNENERGY RESOURCES MEDICAL AND VISION PLAN

2019: PENNENERGY RESOURCES MEDICAL AND VISION PLAN 2019 form 5500 responses
2019-12-01	Type of plan entity	Single employer plan
2019-12-01	First time form 5500 has been submitted	Yes
2019-12-01	Submission has been amended	No
2019-12-01	This submission is the final filing	No
2019-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-12-01	Plan is a collectively bargained plan	No
2019-12-01	Plan funding arrangement – Insurance	Yes
2019-12-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

136225

Policy instance

Insurance contract or identification number	136225
Number of Individuals Covered	284
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $43,580
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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
Welfare Benefit Premiums Paid to Carrier	USD $1,574,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,908
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

136225

Policy instance

Insurance contract or identification number	136225
Number of Individuals Covered	284
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $10,145
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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
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 $366,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,100
Insurance broker organization code?	3

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

136225

Policy instance

Insurance contract or identification number	136225
Number of Individuals Covered	281
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Are there contracts with allocated funds for individual policies?	0
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	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $17,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	PENNENERGY RESOURCES, LLC
Employer identification number (EIN):	452673440
NAIC Classification:	211130
NAIC Description:	Natural Gas Extraction

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	5003495