401k Plan data: NORTH TONAWANDA SUPERMARKET, INC. plan

NORTH TONAWANDA SUPERMARKET, INC. 401k Plan overview

Plan Name	NORTH TONAWANDA SUPERMARKET, INC.
Plan identification number	501

NORTH TONAWANDA SUPERMARKET, INC. Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Long-term disability cover

401k Sponsoring company profile

NORTH TONAWANDA SUPERMARKET, INC. has sponsored the creation of one or more 401k plans.

Company Name: NORTH TONAWANDA SUPERMARKET, INC.

Employer identification number (EIN): 473914728

NAIC Classification: 445110
NAIC Description: Supermarkets and Other Grocery (except Convenience) Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NORTH TONAWANDA SUPERMARKET, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2014-10-01

Plan Statistics for NORTH TONAWANDA SUPERMARKET, INC.

401k plan membership statisitcs for NORTH TONAWANDA SUPERMARKET, INC.

Measure Date Value
2014: NORTH TONAWANDA SUPERMARKET, INC. 2014 401k membership
Total participants, beginning-of-year 2014-10-01 48
Total number of active participants reported on line 7a of the Form 5500 2014-10-01 53
Total of all active and inactive participants 2014-10-01 53

Measure	Date	Value
2014: NORTH TONAWANDA SUPERMARKET, INC. 2014 401k membership
Total participants, beginning-of-year	2014-10-01	48
Total number of active participants reported on line 7a of the Form 5500	2014-10-01	53
Total of all active and inactive participants	2014-10-01	53

Form 5500 Responses for NORTH TONAWANDA SUPERMARKET, INC.

2014: NORTH TONAWANDA SUPERMARKET, INC. 2014 form 5500 responses
2014-10-01	Type of plan entity	Single employer plan
2014-10-01	Plan funding arrangement – Insurance	Yes
2014-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

MP0AE8H

Policy instance

Insurance contract or identification number	MP0AE8H
Number of Individuals Covered	53
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $29
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOC LLC

COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )

Policy contract number

GLCL0AE8H

Policy instance

Insurance contract or identification number	GLCL0AE8H
Number of Individuals Covered	53
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $355
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $355
Insurance broker organization code?	3
Insurance broker name	PREMIER CONSULTING ASSOC LLC

Potentially related plans

NORTH TONAWANDA COMMUNITY FEDERAL CREDIT UNION BASIC CAPITAL ACCUMULATION PLAN [EIN = 161098179]

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Company Name:	NORTH TONAWANDA SUPERMARKET, INC.
Employer identification number (EIN):	473914728
NAIC Classification:	445110
NAIC Description:	Supermarkets and Other Grocery (except Convenience) Stores