401k Plan data: BAYTEX ENERGY USA HEALTH AND WELFARE PLAN plan

BAYTEX ENERGY USA HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	BAYTEX ENERGY USA HEALTH AND WELFARE PLAN
Plan identification number	501

BAYTEX ENERGY USA 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) Long-term disability cover Severance pay Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

BAYTEX ENERGY USA, INC. has sponsored the creation of one or more 401k plans.

Company Name: BAYTEX ENERGY USA, INC.

Employer identification number (EIN): 760389487

NAIC Classification: 211120
NAIC Description: Crude Petroleum Extraction

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BAYTEX ENERGY USA HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 CRAIG MURRAY 2024-06-06

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-01-01	CRAIG MURRAY	2024-06-06

Plan Statistics for BAYTEX ENERGY USA HEALTH AND WELFARE PLAN

401k plan membership statisitcs for BAYTEX ENERGY USA HEALTH AND WELFARE PLAN

Measure Date Value
2023: BAYTEX ENERGY USA HEALTH AND WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 140
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 144
Number of retired or separated participants receiving benefits 2023-01-01 10
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 154
Number of employers contributing to the scheme 2023-01-01 0

Measure	Date	Value
2023: BAYTEX ENERGY USA HEALTH AND WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	140
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	144
Number of retired or separated participants receiving benefits	2023-01-01	10
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	154
Number of employers contributing to the scheme	2023-01-01	0

Form 5500 Responses for BAYTEX ENERGY USA HEALTH AND WELFARE PLAN

2023: BAYTEX ENERGY USA HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

MONUMENTAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 66281 )

Policy contract number

MZ0910579H0000A

Policy instance

Insurance contract or identification number	MZ0910579H0000A
Number of Individuals Covered	5
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $3,048
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

282667

Policy instance

Insurance contract or identification number	282667
Number of Individuals Covered	433
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $108,780
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,508,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

97383111001

Policy instance

Insurance contract or identification number	97383111001
Number of Individuals Covered	452
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,237
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )

Policy contract number

GMDC0BN4Z

Policy instance

Insurance contract or identification number	GMDC0BN4Z
Number of Individuals Covered	84
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $491
Total amount of fees paid to insurance company	USD $263
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $3,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ENVISION INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77399 )

Policy contract number

AWF50251001

Policy instance

Insurance contract or identification number	AWF50251001
Number of Individuals Covered	5
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,169
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $14,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BN4Z

Policy instance

Insurance contract or identification number	GLTD0BN4Z
Number of Individuals Covered	163
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $9,943
Total amount of fees paid to insurance company	USD $10,373
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	EMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $142,085
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

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Company Name:	BAYTEX ENERGY USA, INC.
Employer identification number (EIN):	760389487
NAIC Classification:	211120
NAIC Description:	Crude Petroleum Extraction