401k Plan data: BLOCK 22, LLC HEALTH AND WELFARE PLAN plan

BLOCK 22, LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	BLOCK 22, LLC HEALTH AND WELFARE PLAN
Plan identification number	506

BLOCK 22, LLC 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 Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

BLOCK 22, LLC has sponsored the creation of one or more 401k plans.

Company Name: BLOCK 22, LLC

Employer identification number (EIN): 820485635

NAIC Classification: 721110
NAIC Description: Hotels (except Casino Hotels) and Motels

Additional information about BLOCK 22, LLC

Jurisdiction of Incorporation: Idaho Secretary Of State

Incorporation Date:

Company Identification Number: W1312

More information about BLOCK 22, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLOCK 22, LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2023-09-01 MICHAEL R. CAMPBELL 2024-07-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
506	2023-09-01	MICHAEL R. CAMPBELL	2024-07-01

Form 5500 Responses for BLOCK 22, LLC HEALTH AND WELFARE PLAN

2023: BLOCK 22, LLC HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-09-01	Type of plan entity	Single employer plan
2023-09-01	First time form 5500 has been submitted	Yes
2023-09-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2023-09-01	Plan funding arrangement – Insurance	Yes
2023-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-09-01	Plan benefit arrangement – Insurance	Yes
2023-09-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

BLUE CROSS OF IDAHO HEALTH SERVICE INC. (National Association of Insurance Commissioners NAIC id number: 60095 )

Policy contract number

10034919

Policy instance

Insurance contract or identification number	10034919
Number of Individuals Covered	225
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $34,138
Total amount of fees paid to insurance company	USD $4,620
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $163,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF IDAHO, INC (National Association of Insurance Commissioners NAIC id number: 47791 )

Policy contract number

4761

Policy instance

Insurance contract or identification number	4761
Number of Individuals Covered	147
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

11333

Policy instance

Insurance contract or identification number	11333
Number of Individuals Covered	258
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $6,380
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
Welfare Benefit Premiums Paid to Carrier	USD $69,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	BLOCK 22, LLC
Employer identification number (EIN):	820485635
NAIC Classification:	721110
NAIC Description:	Hotels (except Casino Hotels) and Motels

Jurisdiction of Incorporation:	Idaho Secretary Of State
Incorporation Date:
Company Identification Number:	W1312