401k Plan data: HM INSURANCE GROUP-DAVIS VISION plan

HM INSURANCE GROUP-DAVIS VISION 401k Plan overview

Plan Name	HM INSURANCE GROUP-DAVIS VISION
Plan identification number	521

HM INSURANCE GROUP-DAVIS VISION Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Vision 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

KINGS, QUEENS & JACKS, LLC has sponsored the creation of one or more 401k plans.

Company Name: KINGS, QUEENS & JACKS, LLC

Employer identification number (EIN): 455199308

NAIC Classification: 713200
NAIC Description: Gambling Industries

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HM INSURANCE GROUP-DAVIS VISION

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
521 2017-01-01 ALEX TUCKER ALEX TUCKER 2018-08-06
521 2017-01-01
521 2016-01-01 ALEX TUCKER ALEX TUCKER 2017-07-28
521 2015-01-01 ALEX TUCKER ALEX TUCKER 2016-07-29
521 2014-01-01 ANGIE PETROVIC ALEX TUCKER 2015-06-03

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
521	2017-01-01	ALEX TUCKER	ALEX TUCKER	2018-08-06
521	2017-01-01
521	2016-01-01	ALEX TUCKER	ALEX TUCKER	2017-07-28
521	2015-01-01	ALEX TUCKER	ALEX TUCKER	2016-07-29
521	2014-01-01	ANGIE PETROVIC	ALEX TUCKER	2015-06-03

Plan Statistics for HM INSURANCE GROUP-DAVIS VISION

401k plan membership statisitcs for HM INSURANCE GROUP-DAVIS VISION

Measure Date Value
2017: HM INSURANCE GROUP-DAVIS VISION 2017 401k membership
Total participants, beginning-of-year 2017-01-01 88
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 85
Total of all active and inactive participants 2017-01-01 85
Total participants 2017-01-01 85
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
2016: HM INSURANCE GROUP-DAVIS VISION 2016 401k membership
Total participants, beginning-of-year 2016-01-01 101
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 89
Total of all active and inactive participants 2016-01-01 89
Total participants 2016-01-01 89
2015: HM INSURANCE GROUP-DAVIS VISION 2015 401k membership
Total participants, beginning-of-year 2015-01-01 105
Total of all active and inactive participants 2015-01-01 0
Total participants 2015-01-01 0
2014: HM INSURANCE GROUP-DAVIS VISION 2014 401k membership
Total participants, beginning-of-year 2014-01-01 101
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 0
Total of all active and inactive participants 2014-01-01 0
Total participants 2014-01-01 0

Measure	Date	Value
2017: HM INSURANCE GROUP-DAVIS VISION 2017 401k membership
Total participants, beginning-of-year	2017-01-01	88
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	85
Total of all active and inactive participants	2017-01-01	85
Total participants	2017-01-01	85
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
2016: HM INSURANCE GROUP-DAVIS VISION 2016 401k membership
Total participants, beginning-of-year	2016-01-01	101
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	89
Total of all active and inactive participants	2016-01-01	89
Total participants	2016-01-01	89
2015: HM INSURANCE GROUP-DAVIS VISION 2015 401k membership
Total participants, beginning-of-year	2015-01-01	105
Total of all active and inactive participants	2015-01-01	0
Total participants	2015-01-01	0
2014: HM INSURANCE GROUP-DAVIS VISION 2014 401k membership
Total participants, beginning-of-year	2014-01-01	101
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	0
Total of all active and inactive participants	2014-01-01	0
Total participants	2014-01-01	0

Form 5500 Responses for HM INSURANCE GROUP-DAVIS VISION

2017: HM INSURANCE GROUP-DAVIS VISION 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	First time form 5500 has been submitted	Yes
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: HM INSURANCE GROUP-DAVIS VISION 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 – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: HM INSURANCE GROUP-DAVIS VISION 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 – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: HM INSURANCE GROUP-DAVIS VISION 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 – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

540394-0010

Policy instance

Insurance contract or identification number	540394-0010
Number of Individuals Covered	85
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $627
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 $6,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $627
Total amount of fees paid to insurance company	USD $0
Insurance broker organization code?	3
Insurance broker name	ROSE & KIERNAN

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

540394-0010

Policy instance

Insurance contract or identification number	540394-0010
Number of Individuals Covered	101
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $742
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	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 $7,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $742
Insurance broker name	ROSE & KIERNAN

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

540394 - 0010

Policy instance

Insurance contract or identification number	540394 - 0010
Number of Individuals Covered	101
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $822
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	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 $822,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $822
Insurance broker name	ROSE & KIERNAN

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

540394

Policy instance

Insurance contract or identification number	540394
Number of Individuals Covered	114
Insurance policy start date	2013-02-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $762
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	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 $7,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	KINGS, QUEENS & JACKS, LLC
Employer identification number (EIN):	455199308
NAIC Classification:	713200
NAIC Description:	Gambling Industries