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KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN 401k Plan overview

Plan NameKSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN
Plan identification number 501

KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare 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)
  • Other welfare benefit cover
  • 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

KSA LIGHTING & CONTROLS, INC. has sponsored the creation of one or more 401k plans.

Company Name:KSA LIGHTING & CONTROLS, INC.
Employer identification number (EIN):461568222
NAIC Classification:423600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012020-09-01
5012020-09-01
5012019-09-01TERESA RACE2021-06-11
5012018-09-01

Plan Statistics for KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN

401k plan membership statisitcs for KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN

Measure Date Value
2020: KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-09-01105
Total number of active participants reported on line 7a of the Form 55002020-09-01105
Number of retired or separated participants receiving benefits2020-09-010
Number of other retired or separated participants entitled to future benefits2020-09-010
Total of all active and inactive participants2020-09-01105
2019: KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-09-01115
Total number of active participants reported on line 7a of the Form 55002019-09-01105
Number of retired or separated participants receiving benefits2019-09-010
Number of other retired or separated participants entitled to future benefits2019-09-010
Total of all active and inactive participants2019-09-01105
Number of employers contributing to the scheme2019-09-010
2018: KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-09-01124
Total number of active participants reported on line 7a of the Form 55002018-09-01115
Number of retired or separated participants receiving benefits2018-09-010
Number of other retired or separated participants entitled to future benefits2018-09-010
Total of all active and inactive participants2018-09-01115

Form 5500 Responses for KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN

2020: KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-09-01Type of plan entitySingle employer plan
2020-09-01Submission has been amendedNo
2020-09-01This submission is the final filingNo
2020-09-01This return/report is a short plan year return/report (less than 12 months)No
2020-09-01Plan is a collectively bargained planNo
2020-09-01Plan funding arrangement – InsuranceYes
2020-09-01Plan benefit arrangement – InsuranceYes
2019: KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-09-01Type of plan entitySingle employer plan
2019-09-01Plan funding arrangement – InsuranceYes
2019-09-01Plan funding arrangement – General assets of the sponsorYes
2019-09-01Plan benefit arrangement – InsuranceYes
2019-09-01Plan benefit arrangement – General assets of the sponsorYes
2018: KSA LIGHTING & CONTROLS, INC. HEALTH & WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-09-01Type of plan entitySingle employer plan
2018-09-01First time form 5500 has been submittedYes
2018-09-01Submission has been amendedNo
2018-09-01This submission is the final filingNo
2018-09-01This return/report is a short plan year return/report (less than 12 months)No
2018-09-01Plan is a collectively bargained planNo
2018-09-01Plan funding arrangement – InsuranceYes
2018-09-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BRR2
Policy instance 2
Insurance contract or identification numberG000BRR2
Number of Individuals Covered105
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $17,346
Total amount of fees paid to insurance companyUSD $7,074
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $148,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,346
Amount paid for insurance broker fees1277
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number*SEE BELOW
Policy instance 1
Insurance contract or identification number*SEE BELOW
Number of Individuals Covered150
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $34,558
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $843,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,973
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number98257201001,003
Policy instance 4
Insurance contract or identification number98257201001,003
Number of Individuals Covered221
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $1,232
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,053
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number59791
Policy instance 3
Insurance contract or identification number59791
Number of Individuals Covered105
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $7,077
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $61,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,318
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number11247
Policy instance 2
Insurance contract or identification number11247
Number of Individuals Covered86
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $9,400
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $102,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $6,007
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number191326
Policy instance 1
Insurance contract or identification number191326
Number of Individuals Covered161
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $37,116
Total amount of fees paid to insurance companyUSD $615
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $943,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $8,749
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number*SEE BELOW
Policy instance 5
Insurance contract or identification number*SEE BELOW
Number of Individuals Covered172
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $39,718
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $984,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,718
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number98257201001,003
Policy instance 4
Insurance contract or identification number98257201001,003
Number of Individuals Covered243
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $1,071
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $10,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,071
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number11247
Policy instance 3
Insurance contract or identification number11247
Number of Individuals Covered87
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $9,962
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $91,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,962
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number209680
Policy instance 2
Insurance contract or identification number209680
Number of Individuals Covered43
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $2,312
Total amount of fees paid to insurance companyUSD $35
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE AND AD&D
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 CarrierUSD $13,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,312
Amount paid for insurance broker fees35
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number209719
Policy instance 1
Insurance contract or identification number209719
Number of Individuals Covered115
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $4,991
Total amount of fees paid to insurance companyUSD $116
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 CarrierUSD $44,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,991
Amount paid for insurance broker fees116
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3

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