401k Plan data: COVI CONCRETE CONSTRUCTION EMPLOYEE BENEFIT PLAN plan

COVI CONCRETE CONSTRUCTION EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	COVI CONCRETE CONSTRUCTION EMPLOYEE BENEFIT PLAN
Plan identification number	520

COVI CONCRETE CONSTRUCTION EMPLOYEE BENEFIT PLAN Benefits

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

COVI CONCRETE CONSTRUCTION, INC. has sponsored the creation of one or more 401k plans.

Company Name: COVI CONCRETE CONSTRUCTION, INC.

Employer identification number (EIN): 953661128

NAIC Classification: 236200

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COVI CONCRETE CONSTRUCTION EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
520 2023-07-01
520 2023-07-01 SAMANTHA PHONG
520 2022-07-01
520 2022-07-01 SAMANTHA PHONG
520 2021-07-01
520 2021-07-01 SAMANTHA PHONG

Form 5500 Responses for COVI CONCRETE CONSTRUCTION EMPLOYEE BENEFIT PLAN

2023: COVI CONCRETE CONSTRUCTION EMPLOYEE BENEFIT PLAN 2023 form 5500 responses
2023-07-01	Type of plan entity	Single employer plan
2023-07-01	Submission has been amended	No
2023-07-01	This submission is the final filing	No
2023-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-07-01	Plan is a collectively bargained plan	No
2023-07-01	Plan funding arrangement – Insurance	Yes
2023-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-07-01	Plan benefit arrangement – Insurance	Yes
2023-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: COVI CONCRETE CONSTRUCTION EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Submission has been amended	No
2022-07-01	This submission is the final filing	No
2022-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-07-01	Plan is a collectively bargained plan	No
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: COVI CONCRETE CONSTRUCTION EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
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

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1176520

Policy instance

Insurance contract or identification number	1176520
Number of Individuals Covered	53
Insurance policy start date	2023-07-01
Insurance policy end date	2024-06-30
Total amount of commissions paid to insurance broker	USD $4,472
Total amount of fees paid to insurance company	USD $1,153
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	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 $44,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

0186335

Policy instance

Insurance contract or identification number	0186335
Number of Individuals Covered	145
Insurance policy start date	2023-07-01
Insurance policy end date	2024-06-30
Total amount of commissions paid to insurance broker	USD $37,805
Total amount of fees paid to insurance company	USD $2,500
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 $679,357
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

0186335

Policy instance

Insurance contract or identification number	0186335
Number of Individuals Covered	7
Insurance policy start date	2023-07-01
Insurance policy end date	2024-06-30
Total amount of commissions paid to insurance broker	USD $2,790
Total amount of fees paid to insurance company	USD $4,440
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 $50,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

402399

Policy instance

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

952439

Policy instance

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

Policy contract number

LB534/77423

Policy instance

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30075986

Policy instance

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 61557 )

Policy contract number

W0071392

Policy instance

DENTAL HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 62121 )

Policy contract number

5340HPE

Policy instance

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Company Name:	COVI CONCRETE CONSTRUCTION, INC.
Employer identification number (EIN):	953661128
NAIC Classification:	236200

Plan id#	Filing Submission Date	Name of Administrator
520	2023-07-01
520	2023-07-01	SAMANTHA PHONG
520	2022-07-01
520	2022-07-01	SAMANTHA PHONG
520	2021-07-01
520	2021-07-01	SAMANTHA PHONG