401k Plan data: FIRST NORTHERN BANK-BENEFIT PLAN plan

FIRST NORTHERN BANK-BENEFIT PLAN 401k Plan overview

Plan Name	FIRST NORTHERN BANK-BENEFIT PLAN
Plan identification number	502

FIRST NORTHERN BANK-BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Death benefits (include travel accident but not life insurance) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

FIRST NORTHERN BANK OF DIXON has sponsored the creation of one or more 401k plans.

Company Name: FIRST NORTHERN BANK OF DIXON

Employer identification number (EIN): 940475380

NAIC Classification: 522110
NAIC Description: Commercial Banking

Additional information about FIRST NORTHERN BANK OF DIXON

Jurisdiction of Incorporation: California Department of State

Incorporation Date:

Company Identification Number: C0969517

More information about FIRST NORTHERN BANK OF DIXON

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIRST NORTHERN BANK-BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2004-01-01 KATELYN MORRIS 2023-07-20

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2004-01-01	KATELYN MORRIS	2023-07-20

Form 5500 Responses for FIRST NORTHERN BANK-BENEFIT PLAN

2004: FIRST NORTHERN BANK-BENEFIT PLAN 2004 form 5500 responses
2004-01-01	Type of plan entity	Single employer plan
2004-01-01	Submission has been amended	Yes
2004-01-01	This submission is the final filing	Yes
2004-01-01	Plan funding arrangement – Insurance	Yes
2004-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

600514

Policy instance

Insurance contract or identification number	600514
Number of Individuals Covered	74
Insurance policy start date	2004-01-01
Insurance policy end date	2004-12-31
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 $251,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

65940

Policy instance

Insurance contract or identification number	65940
Number of Individuals Covered	125
Insurance policy start date	2004-01-01
Insurance policy end date	2004-12-31
Total amount of commissions paid to insurance broker	USD $16,152
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $538,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

345465

Policy instance

Insurance contract or identification number	345465
Number of Individuals Covered	220
Insurance policy start date	2004-01-01
Insurance policy end date	2004-12-31
Total amount of commissions paid to insurance broker	USD $9,889
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $96,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

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Company Name:	FIRST NORTHERN BANK OF DIXON
Employer identification number (EIN):	940475380
NAIC Classification:	522110
NAIC Description:	Commercial Banking

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	C0969517