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| Plan Name | GPM SOUTHEAST, LLC HEALTH PLAN |
| Plan identification number | 502 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | GPM SOUTHEAST, LLC |
| Employer identification number (EIN): | 462489565 |
| NAIC Classification: | 445120 |
| NAIC Description: | Convenience Stores |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 502 | 2018-01-01 | TAMMY L. MITCHELL | 2019-10-01 | ||
| 502 | 2018-01-01 | TAMMY L. MITCHELL | 2020-09-21 |
| 2018: GPM SOUTHEAST, LLC HEALTH PLAN 2018 form 5500 responses | ||
|---|---|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | First time form 5500 has been submitted | Yes |
| 2018-01-01 | Submission has been amended | Yes |
| 2018-01-01 | This submission is the final filing | Yes |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) | |
| Policy contract number | 1701709 |
| Policy instance | 1 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) | |
| Policy contract number | 10091511001 |
| Policy instance | 2 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) | |
| Policy contract number | 11258274 |
| Policy instance | 3 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) | |
| Policy contract number | 656841 |
| Policy instance | 4 |
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