401k Plan data: UPSIDE FOODS, INC. HEALTH AND WELFARE PLAN plan

UPSIDE FOODS, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	UPSIDE FOODS, INC. HEALTH AND WELFARE PLAN
Plan identification number	501

UPSIDE FOODS, INC. HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare 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

401k Sponsoring company profile

UPSIDE FOODS, INC. has sponsored the creation of one or more 401k plans.

Company Name: UPSIDE FOODS, INC.

Employer identification number (EIN): 474780183

NAIC Classification: 541700

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UPSIDE FOODS, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-05-01 JODIE COHEN 2023-10-25

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-05-01	JODIE COHEN	2023-10-25

Plan Statistics for UPSIDE FOODS, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for UPSIDE FOODS, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2022: UPSIDE FOODS, INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-05-01 177
Total number of active participants reported on line 7a of the Form 5500 2022-05-01 215
Number of retired or separated participants receiving benefits 2022-05-01 6
Number of other retired or separated participants entitled to future benefits 2022-05-01 0
Total of all active and inactive participants 2022-05-01 221
Number of employers contributing to the scheme 2022-05-01 0

Measure	Date	Value
2022: UPSIDE FOODS, INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-05-01	177
Total number of active participants reported on line 7a of the Form 5500	2022-05-01	215
Number of retired or separated participants receiving benefits	2022-05-01	6
Number of other retired or separated participants entitled to future benefits	2022-05-01	0
Total of all active and inactive participants	2022-05-01	221
Number of employers contributing to the scheme	2022-05-01	0

Form 5500 Responses for UPSIDE FOODS, INC. HEALTH AND WELFARE PLAN

2022: UPSIDE FOODS, INC. HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-05-01	Type of plan entity	Single employer plan
2022-05-01	First time form 5500 has been submitted	Yes
2022-05-01	Plan funding arrangement – Insurance	Yes
2022-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-05-01	Plan benefit arrangement – Insurance	Yes
2022-05-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0111853

Policy instance

Insurance contract or identification number	W0111853
Number of Individuals Covered	215
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $73,491
Total amount of fees paid to insurance company	USD $31,481
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,469,828
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $73,491
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	GENERAL AGENT SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

720326

Policy instance

Insurance contract or identification number	720326
Number of Individuals Covered	103
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $28,900
Total amount of fees paid to insurance company	USD $708
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $586,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,900
Amount paid for insurance broker fees	708
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KM05969952

Policy instance

Insurance contract or identification number	KM05969952
Number of Individuals Covered	428
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $17,895
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $182,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,895
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1127075

Policy instance

Insurance contract or identification number	1127075
Number of Individuals Covered	276
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $8,283
Total amount of fees paid to insurance company	USD $1,670
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $84,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,283
Amount paid for insurance broker fees	1670
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )

Policy contract number

15274672

Policy instance

Insurance contract or identification number	15274672
Number of Individuals Covered	83
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $161
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $3,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $161
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	UPSIDE FOODS, INC.
Employer identification number (EIN):	474780183
NAIC Classification:	541700