401k Plan data: DERBY DENTAL LABORATORY BENEFIT PLAN plan

DERBY DENTAL LABORATORY BENEFIT PLAN 401k Plan overview

Plan Name	DERBY DENTAL LABORATORY BENEFIT PLAN
Plan identification number	501

DERBY DENTAL LABORATORY BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

DERBY DENTAL LABORATORY, INC. has sponsored the creation of one or more 401k plans.

Company Name: DERBY DENTAL LABORATORY, INC.

Employer identification number (EIN): 611128013

NAIC Classification: 621510
NAIC Description: Medical and Diagnostic Laboratories

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DERBY DENTAL LABORATORY BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-11-01 COURTNEY ISHMAEL 2024-04-08

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-11-01	COURTNEY ISHMAEL	2024-04-08

Plan Statistics for DERBY DENTAL LABORATORY BENEFIT PLAN

401k plan membership statisitcs for DERBY DENTAL LABORATORY BENEFIT PLAN

Measure Date Value
2022: DERBY DENTAL LABORATORY BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-11-01 128
Total number of active participants reported on line 7a of the Form 5500 2022-11-01 112
Number of retired or separated participants receiving benefits 2022-11-01 0
Number of other retired or separated participants entitled to future benefits 2022-11-01 0
Total of all active and inactive participants 2022-11-01 112
Number of employers contributing to the scheme 2022-11-01 0

Measure	Date	Value
2022: DERBY DENTAL LABORATORY BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-11-01	128
Total number of active participants reported on line 7a of the Form 5500	2022-11-01	112
Number of retired or separated participants receiving benefits	2022-11-01	0
Number of other retired or separated participants entitled to future benefits	2022-11-01	0
Total of all active and inactive participants	2022-11-01	112
Number of employers contributing to the scheme	2022-11-01	0

Form 5500 Responses for DERBY DENTAL LABORATORY BENEFIT PLAN

2022: DERBY DENTAL LABORATORY BENEFIT PLAN 2022 form 5500 responses
2022-11-01	Type of plan entity	Single employer plan
2022-11-01	First time form 5500 has been submitted	Yes
2022-11-01	Plan funding arrangement – Insurance	Yes
2022-11-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

790528

Policy instance

Insurance contract or identification number	790528
Number of Individuals Covered	80
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $14,943
Total amount of fees paid to insurance company	USD $547
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $615,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,943
Amount paid for insurance broker fees	547
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

790528

Policy instance

Insurance contract or identification number	790528
Number of Individuals Covered	76
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $2,563
Total amount of fees paid to insurance company	USD $1,323
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,563
Amount paid for insurance broker fees	1323
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY OF KENTUCKY INC (National Association of Insurance Commissioners NAIC id number: 60219 )

Policy contract number

790528

Policy instance

Insurance contract or identification number	790528
Number of Individuals Covered	25
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $1,024
Total amount of fees paid to insurance company	USD $194
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,024
Amount paid for insurance broker fees	194
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

LIF94049

Policy instance

Insurance contract or identification number	LIF94049
Number of Individuals Covered	112
Insurance policy start date	2022-02-01
Insurance policy end date	2023-01-31
Total amount of commissions paid to insurance broker	USD $3,548
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $26,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,548
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

Potentially related plans

DERBY DENTAL CARE, PLLC PROFIT SHARING PLAN [EIN = 813173545]

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Company Name:	DERBY DENTAL LABORATORY, INC.
Employer identification number (EIN):	611128013
NAIC Classification:	621510
NAIC Description:	Medical and Diagnostic Laboratories