401k Plan data: PF I CARRUS SERVICES, LLC HEALTH AND WELFARE PLAN plan

PF I CARRUS SERVICES, LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	PF I CARRUS SERVICES, LLC HEALTH AND WELFARE PLAN
Plan identification number	501

PF I CARRUS SERVICES, 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

PF CARRUS SERVICES, LLC has sponsored the creation of one or more 401k plans.

Company Name: PF CARRUS SERVICES, LLC

Employer identification number (EIN): 882146964

NAIC Classification: 611000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PF I CARRUS SERVICES, LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 CERISE LAKE 2024-09-16

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-01-01	CERISE LAKE	2024-09-16

Form 5500 Responses for PF I CARRUS SERVICES, LLC HEALTH AND WELFARE PLAN

2023: PF I CARRUS SERVICES, LLC HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	First time form 5500 has been submitted	Yes
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

Insurance Providers Used on plan

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

492314

Policy instance

Insurance contract or identification number	492314
Number of Individuals Covered	1225
Insurance policy start date	2023-07-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $5,155
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $194,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

10213712

Policy instance

Insurance contract or identification number	10213712
Number of Individuals Covered	150
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

71275

Policy instance

Insurance contract or identification number	71275
Number of Individuals Covered	803
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $34,240
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, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $169,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TELADOC (National Association of Insurance Commissioners NAIC id number: 62199 )

Policy contract number

PF CARRUS

Policy instance

Insurance contract or identification number	PF CARRUS
Number of Individuals Covered	757
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
Other welfare benefits provided	TELEHEALTH
Welfare Benefit Premiums Paid to Carrier	USD $26,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )

Policy contract number

40151290

Policy instance

Insurance contract or identification number	40151290
Number of Individuals Covered	469
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,939
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

492314

Policy instance

Insurance contract or identification number	492314
Number of Individuals Covered	1192
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $11,460
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $324,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

PF INTERACTIVE LLC CHAMBER BENEFIT ARRANGEMENT PLAN [EIN = 812700905]

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Company Name:	PF CARRUS SERVICES, LLC
Employer identification number (EIN):	882146964
NAIC Classification:	611000