401k Plan data: BOLTEX LIFE AND AD&D PLAN plan

BOLTEX LIFE AND AD&D PLAN 401k Plan overview

Plan Name	BOLTEX LIFE AND AD&D PLAN
Plan identification number	503

BOLTEX LIFE AND AD&D PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Dental Vision Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

BOLTEX MANUFACTURING COMPANY, INC. has sponsored the creation of one or more 401k plans.

Company Name: BOLTEX MANUFACTURING COMPANY, INC.

Employer identification number (EIN): 844007772

NAIC Classification: 332110

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BOLTEX LIFE AND AD&D PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2022-10-01 JAMARA RODRIGUEZ 2024-04-01
503 2021-10-01 JAMARA RODRIGUEZ 2023-03-02
503 2020-10-01 JAMARA RODRIGUEZ 2022-04-21
503 2020-10-01 JAMARA RODRIGUEZ 2022-04-21
503 2019-10-01 MARCO BERNOBICH 2021-03-28

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
503	2022-10-01	JAMARA RODRIGUEZ	2024-04-01
503	2021-10-01	JAMARA RODRIGUEZ	2023-03-02
503	2020-10-01	JAMARA RODRIGUEZ	2022-04-21
503	2020-10-01	JAMARA RODRIGUEZ	2022-04-21
503	2019-10-01	MARCO BERNOBICH	2021-03-28

Plan Statistics for BOLTEX LIFE AND AD&D PLAN

401k plan membership statisitcs for BOLTEX LIFE AND AD&D PLAN

Measure Date Value
2022: BOLTEX LIFE AND AD&D PLAN 2022 401k membership
Total participants, beginning-of-year 2022-10-01 145
Total number of active participants reported on line 7a of the Form 5500 2022-10-01 151
Number of retired or separated participants receiving benefits 2022-10-01 0
Number of other retired or separated participants entitled to future benefits 2022-10-01 0
Total of all active and inactive participants 2022-10-01 151
2021: BOLTEX LIFE AND AD&D PLAN 2021 401k membership
Total participants, beginning-of-year 2021-10-01 138
Total number of active participants reported on line 7a of the Form 5500 2021-10-01 145
Number of retired or separated participants receiving benefits 2021-10-01 1
Number of other retired or separated participants entitled to future benefits 2021-10-01 0
Total of all active and inactive participants 2021-10-01 146
2020: BOLTEX LIFE AND AD&D PLAN 2020 401k membership
Total participants, beginning-of-year 2020-10-01 67
Total number of active participants reported on line 7a of the Form 5500 2020-10-01 113
Number of retired or separated participants receiving benefits 2020-10-01 0
Number of other retired or separated participants entitled to future benefits 2020-10-01 0
Total of all active and inactive participants 2020-10-01 113
2019: BOLTEX LIFE AND AD&D PLAN 2019 401k membership
Total participants, beginning-of-year 2019-10-01 201
Total number of active participants reported on line 7a of the Form 5500 2019-10-01 67
Number of retired or separated participants receiving benefits 2019-10-01 0
Number of other retired or separated participants entitled to future benefits 2019-10-01 0
Total of all active and inactive participants 2019-10-01 67

Measure	Date	Value
2022: BOLTEX LIFE AND AD&D PLAN 2022 401k membership
Total participants, beginning-of-year	2022-10-01	145
Total number of active participants reported on line 7a of the Form 5500	2022-10-01	151
Number of retired or separated participants receiving benefits	2022-10-01	0
Number of other retired or separated participants entitled to future benefits	2022-10-01	0
Total of all active and inactive participants	2022-10-01	151
2021: BOLTEX LIFE AND AD&D PLAN 2021 401k membership
Total participants, beginning-of-year	2021-10-01	138
Total number of active participants reported on line 7a of the Form 5500	2021-10-01	145
Number of retired or separated participants receiving benefits	2021-10-01	1
Number of other retired or separated participants entitled to future benefits	2021-10-01	0
Total of all active and inactive participants	2021-10-01	146
2020: BOLTEX LIFE AND AD&D PLAN 2020 401k membership
Total participants, beginning-of-year	2020-10-01	67
Total number of active participants reported on line 7a of the Form 5500	2020-10-01	113
Number of retired or separated participants receiving benefits	2020-10-01	0
Number of other retired or separated participants entitled to future benefits	2020-10-01	0
Total of all active and inactive participants	2020-10-01	113
2019: BOLTEX LIFE AND AD&D PLAN 2019 401k membership
Total participants, beginning-of-year	2019-10-01	201
Total number of active participants reported on line 7a of the Form 5500	2019-10-01	67
Number of retired or separated participants receiving benefits	2019-10-01	0
Number of other retired or separated participants entitled to future benefits	2019-10-01	0
Total of all active and inactive participants	2019-10-01	67

Form 5500 Responses for BOLTEX LIFE AND AD&D PLAN

2022: BOLTEX LIFE AND AD&D PLAN 2022 form 5500 responses
2022-10-01	Type of plan entity	Single employer plan
2022-10-01	Submission has been amended	No
2022-10-01	This submission is the final filing	No
2022-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-10-01	Plan is a collectively bargained plan	No
2022-10-01	Plan funding arrangement – Insurance	Yes
2022-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-10-01	Plan benefit arrangement – Insurance	Yes
2022-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: BOLTEX LIFE AND AD&D PLAN 2021 form 5500 responses
2021-10-01	Type of plan entity	Single employer plan
2021-10-01	Submission has been amended	No
2021-10-01	This submission is the final filing	No
2021-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-10-01	Plan is a collectively bargained plan	No
2021-10-01	Plan funding arrangement – Insurance	Yes
2021-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-10-01	Plan benefit arrangement – Insurance	Yes
2021-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: BOLTEX LIFE AND AD&D PLAN 2020 form 5500 responses
2020-10-01	Type of plan entity	Single employer plan
2020-10-01	Submission has been amended	Yes
2020-10-01	This submission is the final filing	No
2020-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-10-01	Plan is a collectively bargained plan	No
2020-10-01	Plan funding arrangement – Insurance	Yes
2020-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-10-01	Plan benefit arrangement – Insurance	Yes
2020-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: BOLTEX LIFE AND AD&D PLAN 2019 form 5500 responses
2019-10-01	Type of plan entity	Single employer plan
2019-10-01	Submission has been amended	No
2019-10-01	This submission is the final filing	No
2019-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-10-01	Plan is a collectively bargained plan	No
2019-10-01	Plan funding arrangement – Insurance	Yes
2019-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5734711

Policy instance

Insurance contract or identification number	5734711
Number of Individuals Covered	297
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $8,431
Total amount of fees paid to insurance company	USD $1,031
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
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	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $79,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,431
Amount paid for insurance broker fees	38
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )

Policy contract number

5734711

Policy instance

Insurance contract or identification number	5734711
Number of Individuals Covered	114
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $847
Total amount of fees paid to insurance company	USD $106
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $847
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	NA
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5734711

Policy instance

Insurance contract or identification number	5734711
Number of Individuals Covered	290
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $7,172
Total amount of fees paid to insurance company	USD $849
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
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	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $68,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,172
Amount paid for insurance broker fees	34
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )

Policy contract number

5734711

Policy instance

Insurance contract or identification number	5734711
Number of Individuals Covered	141
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $862
Total amount of fees paid to insurance company	USD $108
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $862
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	NA
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5734711

Policy instance

Insurance contract or identification number	5734711
Number of Individuals Covered	166
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $2,387
Total amount of fees paid to insurance company	USD $226
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
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	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $18,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,387
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	NA
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KM05734711

Policy instance

Insurance contract or identification number	KM05734711
Number of Individuals Covered	110
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $3,647
Total amount of fees paid to insurance company	USD $528
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
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 & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $29,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,647
Amount paid for insurance broker fees	528
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

Potentially related plans

BOLTEX LIFE AND AD&D PLAN [EIN = 760525115]

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Company Name:	BOLTEX MANUFACTURING COMPANY, INC.
Employer identification number (EIN):	844007772
NAIC Classification:	332110