401k Plan data: CO-OP 401(K) PLAN plan

CO-OP 401(K) PLAN 401k Plan overview

Plan Name	CO-OP 401(K) PLAN
Plan identification number	002

CO-OP 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Plan provides for automatic enrollment in plan that has employee contributions deducted from payroll.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

NEW HORIZONS SUPPLY COOPERATIVE has sponsored the creation of one or more 401k plans.

Company Name: NEW HORIZONS SUPPLY COOPERATIVE

Employer identification number (EIN): 391663129

NAIC Classification: 453990

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CO-OP 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2022-01-01
002 2021-01-01
002 2020-01-01 ELA PAGENKOPF 2021-09-01
002 2019-01-01 ELA PAGENKOPF 2020-07-17
002 2018-01-01 AMANDA DEGENHARDT 2019-07-26
002 2017-01-01 AMANDA DEGENHARDT 2018-07-19
002 2016-01-01 AMANDA DEGENHARDT 2017-06-27
002 2015-01-01 AMANDA DEGENHARDT 2016-06-21
002 2014-01-01 AMANDA DEGENHARDT 2015-10-06
002 2013-01-01 VERN HRUBES 2014-07-30
002 2012-01-01 K SCOTT MITCHELL 2013-06-18
002 2011-01-01 SCOTT MITCHELL 2012-05-25
002 2010-01-01 LAVERN F HRUBES 2011-05-24

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
002	2022-01-01
002	2021-01-01
002	2020-01-01	ELA PAGENKOPF	2021-09-01
002	2019-01-01	ELA PAGENKOPF	2020-07-17
002	2018-01-01	AMANDA DEGENHARDT	2019-07-26
002	2017-01-01	AMANDA DEGENHARDT	2018-07-19
002	2016-01-01	AMANDA DEGENHARDT	2017-06-27
002	2015-01-01	AMANDA DEGENHARDT	2016-06-21
002	2014-01-01	AMANDA DEGENHARDT	2015-10-06
002	2013-01-01	VERN HRUBES	2014-07-30
002	2012-01-01	K SCOTT MITCHELL	2013-06-18
002	2011-01-01	SCOTT MITCHELL	2012-05-25
002	2010-01-01	LAVERN F HRUBES	2011-05-24

Plan Statistics for CO-OP 401(K) PLAN

401k plan membership statisitcs for CO-OP 401(K) PLAN

Measure Date Value
2022: CO-OP 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 139
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 89
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 50
Total of all active and inactive participants 2022-01-01 139
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 2
Total participants 2022-01-01 141
Number of participants with account balances 2022-01-01 137
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: CO-OP 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 135
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 93
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 44
Total of all active and inactive participants 2021-01-01 137
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 1
Total participants 2021-01-01 138
Number of participants with account balances 2021-01-01 137
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0

Measure	Date	Value
2022: CO-OP 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	139
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	89
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	50
Total of all active and inactive participants	2022-01-01	139
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	2
Total participants	2022-01-01	141
Number of participants with account balances	2022-01-01	137
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: CO-OP 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	135
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	93
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	44
Total of all active and inactive participants	2021-01-01	137
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	1
Total participants	2021-01-01	138
Number of participants with account balances	2021-01-01	137
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0

Financial Data on CO-OP 401(K) PLAN

Measure	Date	Value
2022 : CO-OP 401(K) PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$416
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$691
Total income from all sources (including contributions)	2022-12-31	$-1,050,454
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$899,792
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$865,908
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$426,693
Value of total assets at end of year	2022-12-31	$6,703,187
Value of total assets at beginning of year	2022-12-31	$8,653,708
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$33,884
Total interest from all sources	2022-12-31	$950
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$317,224
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2022-12-31	$317,224
Administrative expenses professional fees incurred	2022-12-31	$32,701
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$193,629
Participant contributions at end of year	2022-12-31	$11,339
Participant contributions at beginning of year	2022-12-31	$15,936
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2022-12-31	$416
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2022-12-31	$691
Other income not declared elsewhere	2022-12-31	$-43,243
Administrative expenses (other) incurred	2022-12-31	$1,183
Total non interest bearing cash at end of year	2022-12-31	$1,243
Total non interest bearing cash at beginning of year	2022-12-31	$98
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-1,950,246
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$6,702,771
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$8,653,017
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$6,244,912
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$7,773,775
Interest on participant loans	2022-12-31	$950
Value of interest in common/collective trusts at end of year	2022-12-31	$9,505
Value of interest in common/collective trusts at beginning of year	2022-12-31	$37,132
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2022-12-31	$82
Asset value of US Government securities at end of year	2022-12-31	$136,537
Asset value of US Government securities at beginning of year	2022-12-31	$358,954
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-1,752,326
Net investment gain or loss from common/collective trusts	2022-12-31	$248
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$233,064
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$865,908
Asset. Corporate debt instrument preferred debt at end of year	2022-12-31	$105,128
Asset. Corporate debt instrument preferred debt at beginning of year	2022-12-31	$157,990
Asset. Corporate debt instrument debt (other) at end of year	2022-12-31	$194,441
Asset. Corporate debt instrument debt (other) at beginning of year	2022-12-31	$309,823
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	WEGNER CPAS LLP
Accountancy firm EIN	2022-12-31	390974031
2021 : CO-OP 401(K) PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$691
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$1,757,062
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$928,081
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$892,890
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$538,376
Value of total assets at end of year	2021-12-31	$8,653,708
Value of total assets at beginning of year	2021-12-31	$7,824,036
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$35,191
Total interest from all sources	2021-12-31	$1,340
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$556,283
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2021-12-31	$556,283
Administrative expenses professional fees incurred	2021-12-31	$33,593
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$204,625
Participant contributions at end of year	2021-12-31	$15,936
Participant contributions at beginning of year	2021-12-31	$23,633
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$112,483
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2021-12-31	$691
Other income not declared elsewhere	2021-12-31	$49,865
Total non interest bearing cash at end of year	2021-12-31	$98
Total non interest bearing cash at beginning of year	2021-12-31	$3,825
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$828,981
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$8,653,017
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$7,824,036
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Investment advisory and management fees	2021-12-31	$1,598
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$7,773,775
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$6,787,330
Interest on participant loans	2021-12-31	$1,340
Value of interest in common/collective trusts at end of year	2021-12-31	$37,132
Value of interest in common/collective trusts at beginning of year	2021-12-31	$1,009,248
Asset value of US Government securities at end of year	2021-12-31	$358,954
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$611,172
Net investment gain or loss from common/collective trusts	2021-12-31	$26
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$221,268
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$892,890
Asset. Corporate debt instrument preferred debt at end of year	2021-12-31	$157,990
Asset. Corporate debt instrument debt (other) at end of year	2021-12-31	$309,823
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	WEGNER CPAS LLP
Accountancy firm EIN	2021-12-31	390974031

Form 5500 Responses for CO-OP 401(K) PLAN

2022: CO-OP 401(K) PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: CO-OP 401(K) PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )

Policy contract number

1666920

Policy instance

Insurance contract or identification number	1666920
Number of Individuals Covered	141
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	Yes
Health Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PACIFIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67466 )

Policy contract number

G-027795

Policy instance

Insurance contract or identification number	G-027795
Number of Individuals Covered	141
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	Yes
Health Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

062491

Policy instance

Insurance contract or identification number	062491
Number of Individuals Covered	141
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	Yes
Health Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MONUMENTAL LIFE (National Association of Insurance Commissioners NAIC id number: 66281 )

Policy contract number

MDA01360TR

Policy instance

Insurance contract or identification number	MDA01360TR
Number of Individuals Covered	141
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	Yes
Health Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )

Policy contract number

1666920

Policy instance

Insurance contract or identification number	1666920
Number of Individuals Covered	138
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	Yes
Health Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PACIFIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67466 )

Policy contract number

G-027795

Policy instance

Insurance contract or identification number	G-027795
Number of Individuals Covered	138
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	Yes
Health Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

062491

Policy instance

Insurance contract or identification number	062491
Number of Individuals Covered	138
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	Yes
Health Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MONUMENTAL LIFE (National Association of Insurance Commissioners NAIC id number: 66281 )

Policy contract number

MDA01360TR

Policy instance

Insurance contract or identification number	MDA01360TR
Number of Individuals Covered	138
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	Yes
Health Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	NEW HORIZONS SUPPLY COOPERATIVE
Employer identification number (EIN):	391663129
NAIC Classification:	453990