401k Plan data: JUPITERMLP, LLC HEALTH AND WELFARE plan

JUPITERMLP, LLC HEALTH AND WELFARE 401k Plan overview

Plan Name	JUPITERMLP, LLC HEALTH AND WELFARE
Plan identification number	501

JUPITERMLP, LLC HEALTH AND WELFARE 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 Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

JUPITERMLP, LLC has sponsored the creation of one or more 401k plans.

Company Name: JUPITERMLP, LLC

Employer identification number (EIN): 812210379

NAIC Classification: 324110
NAIC Description: Petroleum Refineries

Additional information about JUPITERMLP, LLC

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2018-06-07

Company Identification Number: 0803038549

Legal Registered Office Address: PO BOX 1168

ADDISON
United States of America (USA)
75001

More information about JUPITERMLP, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan JUPITERMLP, LLC HEALTH AND WELFARE

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2018-01-01 CASH TAYLOR 2019-10-09

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2018-01-01	CASH TAYLOR	2019-10-09

Plan Statistics for JUPITERMLP, LLC HEALTH AND WELFARE

401k plan membership statisitcs for JUPITERMLP, LLC HEALTH AND WELFARE

Measure Date Value
2018: JUPITERMLP, LLC HEALTH AND WELFARE 2018 401k membership
Total participants, beginning-of-year 2018-01-01 102
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 205
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 205
Number of employers contributing to the scheme 2018-01-01 0

Measure	Date	Value
2018: JUPITERMLP, LLC HEALTH AND WELFARE 2018 401k membership
Total participants, beginning-of-year	2018-01-01	102
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	205
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	205
Number of employers contributing to the scheme	2018-01-01	0

Form 5500 Responses for JUPITERMLP, LLC HEALTH AND WELFARE

2018: JUPITERMLP, LLC HEALTH AND WELFARE 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	First time form 5500 has been submitted	Yes
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

913269

Policy instance

Insurance contract or identification number	913269
Number of Individuals Covered	486
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $-11,852
Total amount of fees paid to insurance company	USD $105,299
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,778,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $-11,852
Amount paid for insurance broker fees	105299
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

10149791001

Policy instance

Insurance contract or identification number	10149791001
Number of Individuals Covered	513
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $534
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $534
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

545848

Policy instance

Insurance contract or identification number	545848
Number of Individuals Covered	63
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,276
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $41,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,276
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F019511

Policy instance

Insurance contract or identification number	F019511
Number of Individuals Covered	192
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $19,425
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $152,988
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,425
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5478145

Policy instance

Insurance contract or identification number	5478145
Number of Individuals Covered	207
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,306
Total amount of fees paid to insurance company	USD $741
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,306
Amount paid for insurance broker fees	741
Additional information about fees paid to insurance broker	FEES AND OTHER COMMISSIONS
Insurance broker organization code?	3

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Company Name:	JUPITERMLP, LLC
Employer identification number (EIN):	812210379
NAIC Classification:	324110
NAIC Description:	Petroleum Refineries

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2018-06-07
Company Identification Number:	0803038549
Legal Registered Office Address:	PO BOX 1168 ADDISON United States of America (USA) 75001