401k Plan data: PURE SAFETY GROUP, INC. HEALTH & WELFARE PLAN plan

PURE SAFETY GROUP, INC. HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	PURE SAFETY GROUP, INC. HEALTH & WELFARE PLAN
Plan identification number	501

PURE SAFETY GROUP, INC. HEALTH & 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)

401k Sponsoring company profile

PURE SAFETY GROUP, INC. has sponsored the creation of one or more 401k plans.

Company Name: PURE SAFETY GROUP, INC.

Employer identification number (EIN): 822198764

NAIC Classification: 339900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PURE SAFETY GROUP, INC. HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-09-01

Plan Statistics for PURE SAFETY GROUP, INC. HEALTH & WELFARE PLAN

401k plan membership statisitcs for PURE SAFETY GROUP, INC. HEALTH & WELFARE PLAN

Measure Date Value
2017: PURE SAFETY GROUP, INC. HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-09-01 100
Total number of active participants reported on line 7a of the Form 5500 2017-09-01 136
Number of retired or separated participants receiving benefits 2017-09-01 0
Number of other retired or separated participants entitled to future benefits 2017-09-01 0
Total of all active and inactive participants 2017-09-01 136

Measure	Date	Value
2017: PURE SAFETY GROUP, INC. HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-09-01	100
Total number of active participants reported on line 7a of the Form 5500	2017-09-01	136
Number of retired or separated participants receiving benefits	2017-09-01	0
Number of other retired or separated participants entitled to future benefits	2017-09-01	0
Total of all active and inactive participants	2017-09-01	136

Form 5500 Responses for PURE SAFETY GROUP, INC. HEALTH & WELFARE PLAN

2017: PURE SAFETY GROUP, INC. HEALTH & WELFARE PLAN 2017 form 5500 responses
2017-09-01	Type of plan entity	Single employer plan
2017-09-01	First time form 5500 has been submitted	Yes
2017-09-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2017-09-01	Plan funding arrangement – Insurance	Yes
2017-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-09-01	Plan benefit arrangement – Insurance	Yes
2017-09-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

542162

Policy instance

Insurance contract or identification number	542162
Number of Individuals Covered	136
Insurance policy start date	2017-09-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,580
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
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 $23,828
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,580
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )

Policy contract number

10034655

Policy instance

Insurance contract or identification number	10034655
Number of Individuals Covered	173
Insurance policy start date	2017-09-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $11,647
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $308,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,647
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFITS SERVICES, INC.

Potentially related plans

PURE SAFETY 401(K) PLAN [EIN = 822218072]

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Company Name:	PURE SAFETY GROUP, INC.
Employer identification number (EIN):	822198764
NAIC Classification:	339900