401k Plan data: NICHOLS CONTRACTING, INC. HEALTH AND WELFARE PLAN plan

NICHOLS CONTRACTING, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	NICHOLS CONTRACTING, INC. HEALTH AND WELFARE PLAN
Plan identification number	501

NICHOLS CONTRACTING, 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) Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

NICHOLS CONTRACTING, INC. has sponsored the creation of one or more 401k plans.

Company Name: NICHOLS CONTRACTING, INC.

Employer identification number (EIN): 521746672

NAIC Classification: 236200

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NICHOLS CONTRACTING, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-10-01 BRANDON SMOLEN 2023-02-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-10-01	BRANDON SMOLEN	2023-02-01

Plan Statistics for NICHOLS CONTRACTING, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for NICHOLS CONTRACTING, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2021: NICHOLS CONTRACTING, INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-10-01 109
Total number of active participants reported on line 7a of the Form 5500 2021-10-01 110
Number of retired or separated participants receiving benefits 2021-10-01 0
Number of other retired or separated participants entitled to future benefits 2021-10-01 0
Total of all active and inactive participants 2021-10-01 110
Number of employers contributing to the scheme 2021-10-01 0

Measure	Date	Value
2021: NICHOLS CONTRACTING, INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-10-01	109
Total number of active participants reported on line 7a of the Form 5500	2021-10-01	110
Number of retired or separated participants receiving benefits	2021-10-01	0
Number of other retired or separated participants entitled to future benefits	2021-10-01	0
Total of all active and inactive participants	2021-10-01	110
Number of employers contributing to the scheme	2021-10-01	0

Form 5500 Responses for NICHOLS CONTRACTING, INC. HEALTH AND WELFARE PLAN

2021: NICHOLS CONTRACTING, INC. HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-10-01	Type of plan entity	Single employer plan
2021-10-01	First time form 5500 has been submitted	Yes
2021-10-01	Plan funding arrangement – Insurance	Yes
2021-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )

Policy contract number

4Y80

Policy instance

Insurance contract or identification number	00536A
Number of Individuals Covered	91
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,031,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $82,536
Additional information about fees paid to insurance broker	SALES & SERVICES
Insurance broker organization code?	3
Total amount of commissions paid to insurance broker	USD $334
Total amount of fees paid to insurance company	USD $42,397
Health Insurance Welfare Benefit	Yes
Amount paid for insurance broker fees	32636

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

Policy contract number

5481499

Policy instance

Insurance contract or identification number	5481499
Number of Individuals Covered	73
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $4,387
Total amount of fees paid to insurance company	USD $1,962
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $49,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,387
Amount paid for insurance broker fees	1240
Additional information about fees paid to insurance broker	TPA ADMINISTRATION FEES
Insurance broker organization code?	5

HEALTH ADVOCATE, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	101
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $2,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

FCX96

Policy instance

Insurance contract or identification number	FCX96
Number of Individuals Covered	5
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $383
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $3,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $181
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	NICHOLS CONTRACTING, INC.
Employer identification number (EIN):	521746672
NAIC Classification:	236200