401k Plan data: DESIGNER FLOORS 401(K) PLAN plan

DESIGNER FLOORS 401(K) PLAN 401k Plan overview

Plan Name	DESIGNER FLOORS 401(K) PLAN
Plan identification number	001

DESIGNER FLOORS 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

DESIGNER FLOORS OF TEXAS has sponsored the creation of one or more 401k plans.

Company Name: DESIGNER FLOORS OF TEXAS

Employer identification number (EIN): 742612893

NAIC Classification: 442210
NAIC Description: Floor Covering Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DESIGNER FLOORS 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2018-01-01 BRANDON SELF 2020-11-13 BRANDON SELF 2020-11-13
001 2017-01-01 BRANDON SELF 2018-10-09 BRANDON SELF 2018-10-09
001 2016-01-01 BRANDON SELF 2017-10-13
001 2015-01-01 BRANDON SELF 2016-07-06
001 2014-01-01 DONNA L. DIXON MICHAEL R. DIXON 2015-07-29
001 2013-01-01 DONNA DIXON MICHAEL DIXON 2014-07-23
001 2012-01-01 DONNA DIXON MICHAEL DIXON 2013-07-30
001 2011-01-01 DONNA DIXON MICHAEL DIXON 2012-07-30
001 2009-01-01 DONNA L. DIXON MICHAEL R. DIXON 2010-07-28

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2018-01-01	BRANDON SELF	2020-11-13	BRANDON SELF	2020-11-13
001	2017-01-01	BRANDON SELF	2018-10-09	BRANDON SELF	2018-10-09
001	2016-01-01	BRANDON SELF	2017-10-13
001	2015-01-01	BRANDON SELF	2016-07-06
001	2014-01-01	DONNA L. DIXON		MICHAEL R. DIXON	2015-07-29
001	2013-01-01	DONNA DIXON		MICHAEL DIXON	2014-07-23
001	2012-01-01	DONNA DIXON		MICHAEL DIXON	2013-07-30
001	2011-01-01	DONNA DIXON		MICHAEL DIXON	2012-07-30
001	2009-01-01	DONNA L. DIXON		MICHAEL R. DIXON	2010-07-28

Plan Statistics for DESIGNER FLOORS 401(K) PLAN

401k plan membership statisitcs for DESIGNER FLOORS 401(K) PLAN

Measure Date Value
2014: DESIGNER FLOORS 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 17
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 16
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 2
Total of all active and inactive participants 2014-01-01 18
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 18
Number of participants with account balances 2014-01-01 9
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: DESIGNER FLOORS 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 17
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 20
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 2
Total of all active and inactive participants 2013-01-01 22
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 22
Number of participants with account balances 2013-01-01 9
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 3
2012: DESIGNER FLOORS 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 19
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 19
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 2
Total of all active and inactive participants 2012-01-01 21
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 21
Number of participants with account balances 2012-01-01 19
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 3
2011: DESIGNER FLOORS 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 20
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 17
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 17
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 17
Number of participants with account balances 2011-01-01 9
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2009: DESIGNER FLOORS 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 21
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 19
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 2
Total of all active and inactive participants 2009-01-01 21
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 1
Total participants 2009-01-01 22
Number of participants with account balances 2009-01-01 10
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2014: DESIGNER FLOORS 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	17
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	16
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	2
Total of all active and inactive participants	2014-01-01	18
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	18
Number of participants with account balances	2014-01-01	9
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: DESIGNER FLOORS 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	17
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	20
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	2
Total of all active and inactive participants	2013-01-01	22
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	22
Number of participants with account balances	2013-01-01	9
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	3
2012: DESIGNER FLOORS 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	19
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	19
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	2
Total of all active and inactive participants	2012-01-01	21
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	21
Number of participants with account balances	2012-01-01	19
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	3
2011: DESIGNER FLOORS 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	20
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	17
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	17
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	17
Number of participants with account balances	2011-01-01	9
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2009: DESIGNER FLOORS 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	21
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	19
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	2
Total of all active and inactive participants	2009-01-01	21
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	1
Total participants	2009-01-01	22
Number of participants with account balances	2009-01-01	10
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on DESIGNER FLOORS 401(K) PLAN

Measure	Date	Value
2014 : DESIGNER FLOORS 401(K) PLAN 2014 401k financial data
Transfers to/from the plan	2014-12-31	$0
Total income from all sources	2014-12-31	$20,903
Expenses. Total of all expenses incurred	2014-12-31	$565
Benefits paid (including direct rollovers)	2014-12-31	$0
Total plan assets at end of year	2014-12-31	$162,500
Total plan assets at beginning of year	2014-12-31	$142,162
Value of fidelity bond covering the plan	2014-12-31	$75,000
Total contributions received or receivable from participants	2014-12-31	$9,599
Expenses. Other expenses not covered elsewhere	2014-12-31	$565
Contributions received from other sources (not participants or employers)	2014-12-31	$0
Other income received	2014-12-31	$11,304
Net income (gross income less expenses)	2014-12-31	$20,338
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$162,500
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$142,162
Assets. Value of participant loans	2014-12-31	$0
Total contributions received or receivable from employer(s)	2014-12-31	$0
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$0
2013 : DESIGNER FLOORS 401(K) PLAN 2013 401k financial data
Transfers to/from the plan	2013-12-31	$0
Total income from all sources	2013-12-31	$36,918
Expenses. Total of all expenses incurred	2013-12-31	$0
Benefits paid (including direct rollovers)	2013-12-31	$0
Total plan assets at end of year	2013-12-31	$142,163
Total plan assets at beginning of year	2013-12-31	$105,245
Value of fidelity bond covering the plan	2013-12-31	$75,000
Total contributions received or receivable from participants	2013-12-31	$5,430
Expenses. Other expenses not covered elsewhere	2013-12-31	$0
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$31,488
Net income (gross income less expenses)	2013-12-31	$36,918
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$142,163
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$105,245
Assets. Value of participant loans	2013-12-31	$0
Total contributions received or receivable from employer(s)	2013-12-31	$0
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$0
2012 : DESIGNER FLOORS 401(K) PLAN 2012 401k financial data
Transfers to/from the plan	2012-12-31	$0
Total income from all sources	2012-12-31	$20,169
Expenses. Total of all expenses incurred	2012-12-31	$0
Benefits paid (including direct rollovers)	2012-12-31	$0
Total plan assets at end of year	2012-12-31	$105,245
Total plan assets at beginning of year	2012-12-31	$85,076
Value of fidelity bond covering the plan	2012-12-31	$75,000
Total contributions received or receivable from participants	2012-12-31	$7,450
Expenses. Other expenses not covered elsewhere	2012-12-31	$0
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$12,719
Net income (gross income less expenses)	2012-12-31	$20,169
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$105,245
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$85,076
Assets. Value of participant loans	2012-12-31	$0
Total contributions received or receivable from employer(s)	2012-12-31	$0
Value of certain deemed distributions of participant loans	2012-12-31	$0
Value of corrective distributions	2012-12-31	$0
2011 : DESIGNER FLOORS 401(K) PLAN 2011 401k financial data
Transfers to/from the plan	2011-12-31	$0
Total income from all sources	2011-12-31	$2,756
Expenses. Total of all expenses incurred	2011-12-31	$50,258
Benefits paid (including direct rollovers)	2011-12-31	$50,258
Total plan assets at end of year	2011-12-31	$85,076
Total plan assets at beginning of year	2011-12-31	$132,578
Value of fidelity bond covering the plan	2011-12-31	$75,000
Total contributions received or receivable from participants	2011-12-31	$8,975
Expenses. Other expenses not covered elsewhere	2011-12-31	$0
Contributions received from other sources (not participants or employers)	2011-12-31	$0
Other income received	2011-12-31	$-6,219
Net income (gross income less expenses)	2011-12-31	$-47,502
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$85,076
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$132,578
Assets. Value of participant loans	2011-12-31	$0
Total contributions received or receivable from employer(s)	2011-12-31	$0
Value of certain deemed distributions of participant loans	2011-12-31	$0
Value of corrective distributions	2011-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2011-12-31	$0
Minimum employer required contribution for this plan year	2011-12-31	$0
Amount contributed by the employer to the plan for this plan year	2011-12-31	$0
2010 : DESIGNER FLOORS 401(K) PLAN 2010 401k financial data
Transfers to/from the plan	2010-12-31	$0
Total income from all sources	2010-12-31	$25,985
Expenses. Total of all expenses incurred	2010-12-31	$0
Benefits paid (including direct rollovers)	2010-12-31	$0
Total plan assets at end of year	2010-12-31	$132,578
Total plan assets at beginning of year	2010-12-31	$106,593
Value of fidelity bond covering the plan	2010-12-31	$75,000
Total contributions received or receivable from participants	2010-12-31	$8,783
Expenses. Other expenses not covered elsewhere	2010-12-31	$0
Contributions received from other sources (not participants or employers)	2010-12-31	$0
Other income received	2010-12-31	$17,202
Net income (gross income less expenses)	2010-12-31	$25,985
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$132,578
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$106,593
Assets. Value of participant loans	2010-12-31	$0
Total contributions received or receivable from employer(s)	2010-12-31	$0
Value of certain deemed distributions of participant loans	2010-12-31	$0
Value of corrective distributions	2010-12-31	$0
2009 : DESIGNER FLOORS 401(K) PLAN 2009 401k financial data
Funding deficiency by the employer to the plan for this plan year	2009-12-31	$0
Minimum employer required contribution for this plan year	2009-12-31	$0
Amount contributed by the employer to the plan for this plan year	2009-12-31	$0

Form 5500 Responses for DESIGNER FLOORS 401(K) PLAN

2014: DESIGNER FLOORS 401(K) PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: DESIGNER FLOORS 401(K) PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: DESIGNER FLOORS 401(K) PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: DESIGNER FLOORS 401(K) PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: DESIGNER FLOORS 401(K) PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-017497

Policy instance

Insurance contract or identification number	GA-017497
Number of Individuals Covered	9
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $560
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $560
Insurance broker organization code?	3
Insurance broker name	JOHN C OLIVER INTERESTS LLC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-017497

Policy instance

Insurance contract or identification number	GA-017497
Number of Individuals Covered	9
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $434
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $434
Insurance broker organization code?	3
Insurance broker name	JOHN C OLIVER INTERESTS LLC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-017497

Policy instance

Insurance contract or identification number	GA-017497
Number of Individuals Covered	9
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $518
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-017497

Policy instance

Insurance contract or identification number	GA-017497
Number of Individuals Covered	10
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $427
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $427
Insurance broker organization code?	3
Insurance broker name	JOHN C OLIVER INTERESTS LLC

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Company Name:	DESIGNER FLOORS OF TEXAS
Employer identification number (EIN):	742612893
NAIC Classification:	442210
NAIC Description:	Floor Covering Stores