401k Plan data: FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST plan

FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 401k Plan overview

Plan Name	FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST
Plan identification number	001

FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

FULL-TILT CONSTRUCTORS has sponsored the creation of one or more 401k plans.

Company Name: FULL-TILT CONSTRUCTORS

Employer identification number (EIN): 454423222

NAIC Classification: 238100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01 CARMEN JOHNSTON 2022-10-14
001 2021-01-01
001 2020-01-01
001 2020-01-01 HEATHER ZARZYCKI 2021-12-13
001 2019-01-01
001 2018-01-01 HEATHER ZARZYCKI 2019-06-27

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2022-01-01	CARMEN JOHNSTON	2022-10-14
001	2021-01-01
001	2020-01-01
001	2020-01-01	HEATHER ZARZYCKI	2021-12-13
001	2019-01-01
001	2018-01-01	HEATHER ZARZYCKI	2019-06-27

Plan Statistics for FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST

401k plan membership statisitcs for FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST

Measure Date Value
2021: FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 2021 401k membership
Total participants, beginning-of-year 2021-01-01 154
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 0
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 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 0
Number of participants with account balances 2021-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 2020 401k membership
Total participants, beginning-of-year 2020-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 135
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 6
Total of all active and inactive participants 2020-01-01 141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 141
Number of participants with account balances 2020-01-01 45
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 2019 401k membership
Total participants, beginning-of-year 2019-01-01 132
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 120
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 4
Total of all active and inactive participants 2019-01-01 124
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 124
Number of participants with account balances 2019-01-01 41
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0

Measure	Date	Value
2021: FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 2021 401k membership
Total participants, beginning-of-year	2021-01-01	154
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	0
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	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	0
Number of participants with account balances	2021-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 2020 401k membership
Total participants, beginning-of-year	2020-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	135
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	6
Total of all active and inactive participants	2020-01-01	141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	141
Number of participants with account balances	2020-01-01	45
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 2019 401k membership
Total participants, beginning-of-year	2019-01-01	132
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	120
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	4
Total of all active and inactive participants	2019-01-01	124
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	124
Number of participants with account balances	2019-01-01	41
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0

Financial Data on FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST

Measure	Date	Value
2021 : FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$438,395
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$1,911,436
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$1,892,979
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$189,793
Value of total assets at end of year	2021-12-31	$287,780
Value of total assets at beginning of year	2021-12-31	$1,760,821
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$18,457
Total interest from all sources	2021-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2021-12-31	$0
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$500,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$111,235
Participant contributions at end of year	2021-12-31	$0
Participant contributions at beginning of year	2021-12-31	$20,171
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$1,755
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$-1,473,041
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$287,780
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$1,760,821
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in pooled separate accounts at end of year	2021-12-31	$287,780
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$1,740,650
Net investment gain/loss from pooled separate accounts	2021-12-31	$248,602
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$76,803
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$1,892,979
Contract administrator fees	2021-12-31	$18,457
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Disclaimer
Accountancy firm name	2021-12-31	THE AMERICAN AUDITORS GROUP, LLC
Accountancy firm EIN	2021-12-31	814229648
2020 : FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$596,890
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$20,833
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$12,522
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$375,038
Value of total assets at end of year	2020-12-31	$1,760,821
Value of total assets at beginning of year	2020-12-31	$1,184,764
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$8,311
Total interest from all sources	2020-12-31	$1,206
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$500,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2020-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$225,455
Participant contributions at end of year	2020-12-31	$20,171
Participant contributions at beginning of year	2020-12-31	$21,818
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$576,057
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$1,760,821
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$1,184,764
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in pooled separate accounts at end of year	2020-12-31	$1,740,650
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$1,162,946
Interest on participant loans	2020-12-31	$1,206
Net investment gain/loss from pooled separate accounts	2020-12-31	$220,646
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$149,583
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$12,522
Contract administrator fees	2020-12-31	$8,311
Did the plan have assets held for investment	2020-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Disclaimer
Accountancy firm name	2020-12-31	THE AMERICAN AUDITORS GROUP, LLC
Accountancy firm EIN	2020-12-31	814229648
2019 : FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$508,344
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$31,755
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$25,434
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$348,063
Value of total assets at end of year	2019-12-31	$1,184,764
Value of total assets at beginning of year	2019-12-31	$708,175
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$6,321
Total interest from all sources	2019-12-31	$1,709
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$500,000
If this is an individual account plan, was there a blackout period	2019-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$205,958
Participant contributions at end of year	2019-12-31	$21,818
Participant contributions at beginning of year	2019-12-31	$27,383
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$7,880
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$476,589
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$1,184,764
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$708,175
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Value of interest in pooled separate accounts at end of year	2019-12-31	$1,162,946
Value of interest in pooled separate accounts at beginning of year	2019-12-31	$680,792
Interest on participant loans	2019-12-31	$1,709
Net investment gain/loss from pooled separate accounts	2019-12-31	$158,572
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Contributions received in cash from employer	2019-12-31	$134,225
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$25,434
Contract administrator fees	2019-12-31	$6,321
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	THE AMERICAN AUDITORS GROUP, LLC
Accountancy firm EIN	2019-12-31	814229648

Form 5500 Responses for FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST

2021: FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 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	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: FULL-TILT 401(K) PROFIT SHARING PLAN AND TRUST 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

GP31874

Policy instance

Insurance contract or identification number	GP31874
Number of Individuals Covered	94
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,193
Total amount of fees paid to insurance company	USD $964
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,193
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	SALES AND BASE COMMISSIONS
Insurance broker organization code?	4

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

GP31874

Policy instance

Insurance contract or identification number	GP31874
Number of Individuals Covered	46
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,678
Total amount of fees paid to insurance company	USD $636
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,678
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	SALES AND BASE COMMISSIONS
Insurance broker organization code?	4

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

GP31874

Policy instance

Insurance contract or identification number	GP31874
Number of Individuals Covered	43
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,521
Total amount of fees paid to insurance company	USD $431
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,625
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	SALES AND BASE COMMISSIONS
Insurance broker organization code?	4

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Company Name:	FULL-TILT CONSTRUCTORS
Employer identification number (EIN):	454423222
NAIC Classification:	238100