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| Plan Name | BLACK LABEL SERVICES, INC. WELFARE BENEFIT PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | BLACK LABEL SERVICES, INC |
| Employer identification number (EIN): | 823601194 |
| NAIC Classification: | 339900 |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2023-01-01 | TRACY NICOLLS | 2024-05-15 | ||
| 501 | 2022-01-01 | TRACY NICOLLS | 2023-07-13 |
| 2023: BLACK LABEL SERVICES, INC. WELFARE BENEFIT 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 |
| 2022: BLACK LABEL SERVICES, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses | ||
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | First time form 5500 has been submitted | Yes |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |||||||||||||||||||||||||||||||||
| Policy contract number | 27071 | ||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) | |||||||||||||||||||||||||||||||||
| Policy contract number | AI110289 | ||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |||||||||||||||||||||||||||||||||
| Policy contract number | 27071 | ||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||
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