401k Plan data: AFFILIATED BANK HEALTH PLAN plan

AFFILIATED BANK HEALTH PLAN 401k Plan overview

Plan Name	AFFILIATED BANK HEALTH PLAN
Plan identification number	501

AFFILIATED BANK HEALTH PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision)

401k Sponsoring company profile

SUSSER BANK has sponsored the creation of one or more 401k plans.

Company Name: SUSSER BANK

Employer identification number (EIN): 751630026

NAIC Classification: 522120
NAIC Description: Savings Institutions

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AFFILIATED BANK HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2014-04-01 RICHARD DRISCOLL
501 2013-04-01 RICHARD DRISCOLL

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2014-04-01	RICHARD DRISCOLL
501	2013-04-01	RICHARD DRISCOLL

Plan Statistics for AFFILIATED BANK HEALTH PLAN

401k plan membership statisitcs for AFFILIATED BANK HEALTH PLAN

Measure Date Value
2014: AFFILIATED BANK HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year 2014-04-01 124
Total number of active participants reported on line 7a of the Form 5500 2014-04-01 0
Number of retired or separated participants receiving benefits 2014-04-01 0
Number of other retired or separated participants entitled to future benefits 2014-04-01 0
Total of all active and inactive participants 2014-04-01 0
2013: AFFILIATED BANK HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year 2013-04-01 139
Total number of active participants reported on line 7a of the Form 5500 2013-04-01 125
Number of retired or separated participants receiving benefits 2013-04-01 4
Number of other retired or separated participants entitled to future benefits 2013-04-01 0
Total of all active and inactive participants 2013-04-01 129

Measure	Date	Value
2014: AFFILIATED BANK HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year	2014-04-01	124
Total number of active participants reported on line 7a of the Form 5500	2014-04-01	0
Number of retired or separated participants receiving benefits	2014-04-01	0
Number of other retired or separated participants entitled to future benefits	2014-04-01	0
Total of all active and inactive participants	2014-04-01	0
2013: AFFILIATED BANK HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year	2013-04-01	139
Total number of active participants reported on line 7a of the Form 5500	2013-04-01	125
Number of retired or separated participants receiving benefits	2013-04-01	4
Number of other retired or separated participants entitled to future benefits	2013-04-01	0
Total of all active and inactive participants	2013-04-01	129

Form 5500 Responses for AFFILIATED BANK HEALTH PLAN

2014: AFFILIATED BANK HEALTH PLAN 2014 form 5500 responses
2014-04-01	Type of plan entity	Single employer plan
2014-04-01	Submission has been amended	No
2014-04-01	This submission is the final filing	Yes
2014-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-04-01	Plan is a collectively bargained plan	No
2014-04-01	Plan funding arrangement – Insurance	Yes
2014-04-01	Plan benefit arrangement – Insurance	Yes
2013: AFFILIATED BANK HEALTH PLAN 2013 form 5500 responses
2013-04-01	Type of plan entity	Single employer plan
2013-04-01	First time form 5500 has been submitted	Yes
2013-04-01	Submission has been amended	No
2013-04-01	This submission is the final filing	No
2013-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-04-01	Plan is a collectively bargained plan	No
2013-04-01	Plan funding arrangement – Insurance	Yes
2013-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

38449, 38764

Policy instance

Insurance contract or identification number	38449, 38764
Number of Individuals Covered	207
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $48,689
Total amount of fees paid to insurance company	USD $1,824
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?	No
Health Insurance Welfare Benefit	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $1,015,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,689
Amount paid for insurance broker fees	1824
Additional information about fees paid to insurance broker	TEXAS BLUE RIBBON PRODUCER BONUS
Insurance broker organization code?	3
Insurance broker name	HEFA OPERATING LLC

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

38449

Policy instance

Insurance contract or identification number	38449
Number of Individuals Covered	125
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $64,939
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?	No
Health Insurance Welfare Benefit	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $1,306,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $64,939
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	HEFA OPERATING LLC

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Company Name:	SUSSER BANK
Employer identification number (EIN):	751630026
NAIC Classification:	522120
NAIC Description:	Savings Institutions