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HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 401k Plan overview

Plan NameHOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN
Plan identification number 501

HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE 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

401k Sponsoring company profile

HOME GROWN INDUSTRIES OF GEORGIA INC. DBA MELLOW MUSHROOM has sponsored the creation of one or more 401k plans.

Company Name:HOME GROWN INDUSTRIES OF GEORGIA INC. DBA MELLOW MUSHROOM
Employer identification number (EIN):581217893
NAIC Classification:722300
NAIC Description: Special Food Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-04-01JANINE TEPROVICH2023-11-08
5012021-04-01
5012020-04-01
5012019-04-01
5012018-04-01
5012017-04-01JANINE TEPROVICH
5012016-04-01JANINE TEPROVICH
5012015-04-01JANINE TEPROVICH

Plan Statistics for HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN

401k plan membership statisitcs for HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN

Measure Date Value
2022: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-04-01100
Total number of active participants reported on line 7a of the Form 55002022-04-01107
Number of retired or separated participants receiving benefits2022-04-010
Number of other retired or separated participants entitled to future benefits2022-04-010
Total of all active and inactive participants2022-04-01107
Number of employers contributing to the scheme2022-04-010
2021: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-04-0181
Total number of active participants reported on line 7a of the Form 55002021-04-0194
Total of all active and inactive participants2021-04-0194
2020: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-04-01115
Total number of active participants reported on line 7a of the Form 55002020-04-0181
Total of all active and inactive participants2020-04-0181
2019: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-04-01109
Total number of active participants reported on line 7a of the Form 55002019-04-01115
Total of all active and inactive participants2019-04-01115
2018: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-04-01117
Total number of active participants reported on line 7a of the Form 55002018-04-01109
Total of all active and inactive participants2018-04-01109
2017: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-04-01124
Total number of active participants reported on line 7a of the Form 55002017-04-01117
Total of all active and inactive participants2017-04-01117
2016: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-04-01107
Total number of active participants reported on line 7a of the Form 55002016-04-01124
Total of all active and inactive participants2016-04-01124
2015: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-04-01137
Total number of active participants reported on line 7a of the Form 55002015-04-01107
Total of all active and inactive participants2015-04-01107

Form 5500 Responses for HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN

2022: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2022 form 5500 responses
2022-04-01Type of plan entitySingle employer plan
2022-04-01Plan funding arrangement – InsuranceYes
2022-04-01Plan funding arrangement – General assets of the sponsorYes
2022-04-01Plan benefit arrangement – InsuranceYes
2022-04-01Plan benefit arrangement – General assets of the sponsorYes
2021: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2021 form 5500 responses
2021-04-01Type of plan entitySingle employer plan
2021-04-01Submission has been amendedNo
2021-04-01This submission is the final filingNo
2021-04-01This return/report is a short plan year return/report (less than 12 months)No
2021-04-01Plan is a collectively bargained planNo
2021-04-01Plan funding arrangement – InsuranceYes
2021-04-01Plan funding arrangement – General assets of the sponsorYes
2021-04-01Plan benefit arrangement – InsuranceYes
2021-04-01Plan benefit arrangement – General assets of the sponsorYes
2020: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2020 form 5500 responses
2020-04-01Type of plan entitySingle employer plan
2020-04-01Submission has been amendedNo
2020-04-01This submission is the final filingNo
2020-04-01This return/report is a short plan year return/report (less than 12 months)No
2020-04-01Plan is a collectively bargained planNo
2020-04-01Plan funding arrangement – InsuranceYes
2020-04-01Plan funding arrangement – General assets of the sponsorYes
2020-04-01Plan benefit arrangement – InsuranceYes
2020-04-01Plan benefit arrangement – General assets of the sponsorYes
2019: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2019 form 5500 responses
2019-04-01Type of plan entitySingle employer plan
2019-04-01Submission has been amendedNo
2019-04-01This submission is the final filingNo
2019-04-01This return/report is a short plan year return/report (less than 12 months)No
2019-04-01Plan is a collectively bargained planNo
2019-04-01Plan funding arrangement – InsuranceYes
2019-04-01Plan funding arrangement – General assets of the sponsorYes
2019-04-01Plan benefit arrangement – InsuranceYes
2019-04-01Plan benefit arrangement – General assets of the sponsorYes
2018: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2018 form 5500 responses
2018-04-01Type of plan entitySingle employer plan
2018-04-01Submission has been amendedNo
2018-04-01This submission is the final filingNo
2018-04-01This return/report is a short plan year return/report (less than 12 months)No
2018-04-01Plan is a collectively bargained planNo
2018-04-01Plan funding arrangement – InsuranceYes
2018-04-01Plan funding arrangement – General assets of the sponsorYes
2018-04-01Plan benefit arrangement – InsuranceYes
2018-04-01Plan benefit arrangement – General assets of the sponsorYes
2017: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2017 form 5500 responses
2017-04-01Type of plan entitySingle employer plan
2017-04-01Submission has been amendedNo
2017-04-01This submission is the final filingNo
2017-04-01This return/report is a short plan year return/report (less than 12 months)No
2017-04-01Plan is a collectively bargained planNo
2017-04-01Plan funding arrangement – InsuranceYes
2017-04-01Plan funding arrangement – General assets of the sponsorYes
2017-04-01Plan benefit arrangement – InsuranceYes
2017-04-01Plan benefit arrangement – General assets of the sponsorYes
2016: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01Submission has been amendedNo
2016-04-01This submission is the final filingNo
2016-04-01This return/report is a short plan year return/report (less than 12 months)No
2016-04-01Plan is a collectively bargained planNo
2016-04-01Plan funding arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – InsuranceYes
2015: HOME GROWN INDUSTRIES OF GEORGIA INC. WELFARE PLAN 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01First time form 5500 has been submittedYes
2015-04-01Submission has been amendedNo
2015-04-01This submission is the final filingNo
2015-04-01This return/report is a short plan year return/report (less than 12 months)No
2015-04-01Plan is a collectively bargained planNo
2015-04-01Plan funding arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number585626
Policy instance 2
Insurance contract or identification number585626
Number of Individuals Covered107
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $25,098
Total amount of fees paid to insurance companyUSD $5,567
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $115,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,301
Amount paid for insurance broker fees5567
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9956517
Policy instance 1
Insurance contract or identification number9956517
Number of Individuals Covered139
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $848
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $848
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00585626
Policy instance 3
Insurance contract or identification number00585626
Number of Individuals Covered94
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $41,619
Total amount of fees paid to insurance companyUSD $4,052
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $107,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,482
Amount paid for insurance broker fees4052
Additional information about fees paid to insurance brokerBONUA
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number618557
Policy instance 2
Insurance contract or identification number618557
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $239,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99565171
Policy instance 1
Insurance contract or identification number99565171
Number of Individuals Covered120
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $972
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $972
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B5PD
Policy instance 3
Insurance contract or identification numberG000B5PD
Number of Individuals Covered81
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $15,364
Total amount of fees paid to insurance companyUSD $6,000
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $117,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $15,364
Amount paid for insurance broker fees6000
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number618557
Policy instance 2
Insurance contract or identification number618557
Number of Individuals Covered99
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $228,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99565171
Policy instance 1
Insurance contract or identification number99565171
Number of Individuals Covered125
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $989
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
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?Yes
Health Insurance Welfare BenefitNo
Dental 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
Commission paid to Insurance BrokerUSD $989
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B5PD
Policy instance 3
Insurance contract or identification numberG000B5PD
Number of Individuals Covered115
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $15,961
Total amount of fees paid to insurance companyUSD $3,725
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $125,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,961
Amount paid for insurance broker fees3725
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number618557
Policy instance 2
Insurance contract or identification number618557
Number of Individuals Covered126
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $270,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99565171
Policy instance 1
Insurance contract or identification number99565171
Number of Individuals Covered159
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $1,177
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,177
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B5PD
Policy instance 3
Insurance contract or identification numberG000B5PD
Number of Individuals Covered109
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $15,663
Total amount of fees paid to insurance companyUSD $3,058
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $117,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,663
Amount paid for insurance broker fees3058
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99565171
Policy instance 2
Insurance contract or identification number99565171
Number of Individuals Covered150
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $872
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $872
Amount paid for insurance broker fees0
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number618557
Policy instance 1
Insurance contract or identification number618557
Number of Individuals Covered125
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $2,736
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $265,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees2736
Additional information about fees paid to insurance brokerINCENTIVE COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B5PD
Policy instance 2
Insurance contract or identification numberG000B5PD
Number of Individuals Covered117
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $12,174
Total amount of fees paid to insurance companyUSD $2,254
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $102,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,174
Amount paid for insurance broker fees2254
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameNORTHWESTERN BENEFIT CORP OF GA
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9956517/9956525
Policy instance 1
Insurance contract or identification number9956517/9956525
Number of Individuals Covered143
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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