401k Plan data: PORTRAIT STUDIO WELFARE PLAN plan

PORTRAIT STUDIO WELFARE PLAN 401k Plan overview

Plan Name	PORTRAIT STUDIO WELFARE PLAN
Plan identification number	501

PORTRAIT STUDIO WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

PORTRAIT STUDIO LLC has sponsored the creation of one or more 401k plans.

Company Name: PORTRAIT STUDIO LLC

Employer identification number (EIN): 823677664

NAIC Classification: 541920

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PORTRAIT STUDIO WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-01-01 JOHN GROSSO 2020-03-12
501 2018-01-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2019-01-01	JOHN GROSSO	2020-03-12
501	2018-01-01

Plan Statistics for PORTRAIT STUDIO WELFARE PLAN

401k plan membership statisitcs for PORTRAIT STUDIO WELFARE PLAN

Measure Date Value
2019: PORTRAIT STUDIO WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 223
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 0
Number of employers contributing to the scheme 2019-01-01 0
2018: PORTRAIT STUDIO WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 293
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 223
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 2018-01-01 223
Number of employers contributing to the scheme 2018-01-01 0

Measure	Date	Value
2019: PORTRAIT STUDIO WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	223
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	0
Number of employers contributing to the scheme	2019-01-01	0
2018: PORTRAIT STUDIO WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	293
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	223
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	223
Number of employers contributing to the scheme	2018-01-01	0

Form 5500 Responses for PORTRAIT STUDIO WELFARE PLAN

2019: PORTRAIT STUDIO WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	This submission is the final filing	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: PORTRAIT STUDIO WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

80900

Policy instance

Insurance contract or identification number	80900
Number of Individuals Covered	75
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $336,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL139685

Policy instance

Insurance contract or identification number	GL139685
Number of Individuals Covered	223
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,745
Total amount of fees paid to insurance company	USD $0
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $8,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,745
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

80900

Policy instance

Insurance contract or identification number	80900
Number of Individuals Covered	78
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $498,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL139685

Policy instance

Insurance contract or identification number	GL139685
Number of Individuals Covered	290
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,102
Total amount of fees paid to insurance company	USD $0
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $10,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,102
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	PORTRAIT STUDIO LLC
Employer identification number (EIN):	823677664
NAIC Classification:	541920