401k Plan data: EMPLOYEE BENEFIT PLAN plan

EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	EMPLOYEE BENEFIT PLAN
Plan identification number	501

EMPLOYEE BENEFIT 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)

401k Sponsoring company profile

DELTA AUTOMOTIVE SERVICES, INC. has sponsored the creation of one or more 401k plans.

Company Name: DELTA AUTOMOTIVE SERVICES, INC.

Employer identification number (EIN): 223647484

NAIC Classification: 811110
NAIC Description: Automotive Mechanical and Electrical Repair and Maintenance

Additional information about DELTA AUTOMOTIVE SERVICES, INC.

Jurisdiction of Incorporation: Florida Department of State Division of Corporations

Incorporation Date: 1988-03-29

Company Identification Number: M74279

Legal Registered Office Address: 3260 HORSESHOE TRAIL

TALLAHASSEE

32312

More information about DELTA AUTOMOTIVE SERVICES, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 JULIE ROCCANOVA 2023-03-29
501 2021-01-01 JULIE ROCCANOVA 2022-02-28
501 2020-01-01 JULIE ROCCANOVA 2021-08-10

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	JULIE ROCCANOVA	2023-03-29
501	2021-01-01	JULIE ROCCANOVA	2022-02-28
501	2020-01-01	JULIE ROCCANOVA	2021-08-10

Plan Statistics for EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 120
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 137
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 137
Number of employers contributing to the scheme 2022-01-01 0
2021: EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 136
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 120
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 120
Number of employers contributing to the scheme 2021-01-01 0
2020: EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 136
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 136
Number of employers contributing to the scheme 2020-01-01 0

Measure	Date	Value
2022: EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	120
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	137
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	137
Number of employers contributing to the scheme	2022-01-01	0
2021: EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	136
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	120
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	120
Number of employers contributing to the scheme	2021-01-01	0
2020: EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	136
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	136
Number of employers contributing to the scheme	2020-01-01	0

Form 5500 Responses for EMPLOYEE BENEFIT PLAN

2022: EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	First time form 5500 has been submitted	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

629568

Policy instance

Insurance contract or identification number	629568
Number of Individuals Covered	161
Insurance policy start date	2022-05-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,611
Total amount of fees paid to insurance company	USD $68,112
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,193,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,620
Amount paid for insurance broker fees	43705
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

629568

Policy instance

Insurance contract or identification number	629568
Number of Individuals Covered	164
Insurance policy start date	2021-05-01
Insurance policy end date	2022-04-30
Total amount of commissions paid to insurance broker	USD $7,336
Total amount of fees paid to insurance company	USD $95,526
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,643,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,581
Amount paid for insurance broker fees	47857
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES, INCENTIVE COMPENSATION
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

880466G

Policy instance

Insurance contract or identification number	880466G
Number of Individuals Covered	32
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,898
Total amount of fees paid to insurance company	USD $196
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,577
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

942

Policy instance

Insurance contract or identification number	942
Number of Individuals Covered	137
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,803
Total amount of fees paid to insurance company	USD $-476
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,495
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SERVICE FEE

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

629568

Policy instance

Insurance contract or identification number	629568
Number of Individuals Covered	180
Insurance policy start date	2020-05-01
Insurance policy end date	2021-04-30
Total amount of commissions paid to insurance broker	USD $7,685
Total amount of fees paid to insurance company	USD $83,215
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,481,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,685
Amount paid for insurance broker fees	53079
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

880466G

Policy instance

Insurance contract or identification number	880466G
Number of Individuals Covered	23
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $905
Total amount of fees paid to insurance company	USD $423
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $984
Amount paid for insurance broker fees	501
Additional information about fees paid to insurance broker	FEES, BONUS
Insurance broker organization code?	3

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

942

Policy instance

Insurance contract or identification number	942
Number of Individuals Covered	120
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,331
Total amount of fees paid to insurance company	USD $1,221
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,221
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SERVICE FEE

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

Policy contract number

05Y5784

Policy instance

Insurance contract or identification number	05Y5784
Number of Individuals Covered	148
Insurance policy start date	2020-01-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $919
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $919
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

880466G

Policy instance

Insurance contract or identification number	880466G
Number of Individuals Covered	18
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,106
Total amount of fees paid to insurance company	USD $121
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,024
Insurance broker organization code?	3
Amount paid for insurance broker fees	121
Additional information about fees paid to insurance broker	BONUS

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

000942

Policy instance

Insurance contract or identification number	000942
Number of Individuals Covered	136
Insurance policy start date	2020-05-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,499
Total amount of fees paid to insurance company	USD $2,062
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,499
Insurance broker organization code?	3
Amount paid for insurance broker fees	1312
Additional information about fees paid to insurance broker	BONUS

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

DA11853

Policy instance

Insurance contract or identification number	DA11853
Number of Individuals Covered	218
Insurance policy start date	2020-01-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $14,335
Total amount of fees paid to insurance company	USD $6,272
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $446,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,335
Amount paid for insurance broker fees	435
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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Company Name:	DELTA AUTOMOTIVE SERVICES, INC.
Employer identification number (EIN):	223647484
NAIC Classification:	811110
NAIC Description:	Automotive Mechanical and Electrical Repair and Maintenance

Jurisdiction of Incorporation:	Florida Department of State Division of Corporations
Incorporation Date:	1988-03-29
Company Identification Number:	M74279
Legal Registered Office Address:	3260 HORSESHOE TRAIL TALLAHASSEE 32312