401k Plan data: SUN CITY REPLACEMENT WINDOW LLC EMPLOYEE BENEFITS PLAN plan

SUN CITY REPLACEMENT WINDOW LLC EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	SUN CITY REPLACEMENT WINDOW LLC EMPLOYEE BENEFITS PLAN
Plan identification number	501

SUN CITY REPLACEMENT WINDOW LLC EMPLOYEE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Other welfare benefit cover

401k Sponsoring company profile

SUN CITY REPLACEMENT WINDOW LLC has sponsored the creation of one or more 401k plans.

Company Name: SUN CITY REPLACEMENT WINDOW LLC

Employer identification number (EIN): 923947532

NAIC Classification: 238300

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SUN CITY REPLACEMENT WINDOW LLC EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-12-01

Plan Statistics for SUN CITY REPLACEMENT WINDOW LLC EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for SUN CITY REPLACEMENT WINDOW LLC EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: SUN CITY REPLACEMENT WINDOW LLC EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-12-01 111
Total number of active participants reported on line 7a of the Form 5500 2022-12-01 117
Number of retired or separated participants receiving benefits 2022-12-01 0
Number of other retired or separated participants entitled to future benefits 2022-12-01 0
Total of all active and inactive participants 2022-12-01 117

Measure	Date	Value
2022: SUN CITY REPLACEMENT WINDOW LLC EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-12-01	111
Total number of active participants reported on line 7a of the Form 5500	2022-12-01	117
Number of retired or separated participants receiving benefits	2022-12-01	0
Number of other retired or separated participants entitled to future benefits	2022-12-01	0
Total of all active and inactive participants	2022-12-01	117

Form 5500 Responses for SUN CITY REPLACEMENT WINDOW LLC EMPLOYEE BENEFITS PLAN

2022: SUN CITY REPLACEMENT WINDOW LLC EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-12-01	Type of plan entity	Single employer plan
2022-12-01	First time form 5500 has been submitted	Yes
2022-12-01	Submission has been amended	No
2022-12-01	This submission is the final filing	Yes
2022-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-12-01	Plan is a collectively bargained plan	No
2022-12-01	Plan funding arrangement – Insurance	Yes
2022-12-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 95473 )

Policy contract number

196667

Policy instance

Insurance contract or identification number	196667
Number of Individuals Covered	27
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
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	Yes
Dental Insurance Welfare Benefit	No
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 $187,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )

Policy contract number

196667

Policy instance

Insurance contract or identification number	196667
Number of Individuals Covered	69
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $28,964
Total amount of fees paid to insurance company	USD $0
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	Yes
Dental Insurance Welfare Benefit	No
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 $658,943
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,964
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CM10001212

Policy instance

Insurance contract or identification number	CM10001212
Number of Individuals Covered	144
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $4,542
Total amount of fees paid to insurance company	USD $380
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 AND DISMEMBERMENT, SUPPLEMENTAL LIFE, DEPENDENT LIFE
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 $21,255
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,542
Amount paid for insurance broker fees	380
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

00027146

Policy instance

Insurance contract or identification number	00027146
Number of Individuals Covered	102
Insurance policy start date	2022-12-01
Insurance policy end date	2023-11-30
Total amount of commissions paid to insurance broker	USD $17,542
Total amount of fees paid to insurance company	USD $5,205
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	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY
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 $92,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,387
Insurance broker organization code?	3
Amount paid for insurance broker fees	5205
Additional information about fees paid to insurance broker	FEES

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Company Name:	SUN CITY REPLACEMENT WINDOW LLC
Employer identification number (EIN):	923947532
NAIC Classification:	238300