401k Plan data: CHILDREN'S DAY SCHOOL WELFARE PLAN plan

CHILDREN'S DAY SCHOOL WELFARE PLAN 401k Plan overview

Plan Name	CHILDREN'S DAY SCHOOL WELFARE PLAN
Plan identification number	501

CHILDREN'S DAY SCHOOL WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

CHILDRENS DAY SCHOOL has sponsored the creation of one or more 401k plans.

Company Name: CHILDRENS DAY SCHOOL

Employer identification number (EIN): 943248631

NAIC Classification: 611000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CHILDREN'S DAY SCHOOL WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-07-01 JESSICA ALVA 2023-01-25 JEANNE JACOBS-GAFFNEY 2023-01-25
501 2021-07-01 JESSICA ALVA 2023-06-05 JEANNE JACOBS-GAFFNEY 2023-06-05

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-07-01	JESSICA ALVA	2023-01-25	JEANNE JACOBS-GAFFNEY	2023-01-25
501	2021-07-01	JESSICA ALVA	2023-06-05	JEANNE JACOBS-GAFFNEY	2023-06-05

Plan Statistics for CHILDREN'S DAY SCHOOL WELFARE PLAN

401k plan membership statisitcs for CHILDREN'S DAY SCHOOL WELFARE PLAN

Measure Date Value
2021: CHILDREN'S DAY SCHOOL WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 101
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 100
Number of retired or separated participants receiving benefits 2021-07-01 1
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 101

Measure	Date	Value
2021: CHILDREN'S DAY SCHOOL WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	101
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	100
Number of retired or separated participants receiving benefits	2021-07-01	1
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	101

Form 5500 Responses for CHILDREN'S DAY SCHOOL WELFARE PLAN

2021: CHILDREN'S DAY SCHOOL WELFARE PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	First time form 5500 has been submitted	Yes
2021-07-01	Submission has been amended	No
2021-07-01	This submission is the final filing	No
2021-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-07-01	Plan is a collectively bargained plan	No
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

408337

Policy instance

Insurance contract or identification number	408337
Number of Individuals Covered	100
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $21,119
Total amount of fees paid to insurance company	USD $1,563
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	BASIC AND VOLUNTARY 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 $50,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,211
Insurance broker organization code?	3
Amount paid for insurance broker fees	1563
Additional information about fees paid to insurance broker	FEES

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

Policy contract number

636285

Policy instance

Insurance contract or identification number	636285
Number of Individuals Covered	107
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $51,463
Total amount of fees paid to insurance company	USD $792
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 $812,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,199
Amount paid for insurance broker fees	792
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

03W2753

Policy instance

Insurance contract or identification number	03W2753
Number of Individuals Covered	16
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $9,134
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 $139,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,134
Insurance broker organization code?	3

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Company Name:	CHILDRENS DAY SCHOOL
Employer identification number (EIN):	943248631
NAIC Classification:	611000