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| Plan Name | SHORT-TERM DISABILITY |
| Plan identification number | 507 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | LAKE STATES TREE SERVICE, INC. |
| Employer identification number (EIN): | 410810558 |
| NAIC Classification: | 561730 |
| NAIC Description: | Landscaping Services |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 507 | 2019-09-01 | TINA LAVERDURE | 2021-01-14 | ||
| 507 | 2019-09-01 | TINA LAVERDURE | 2021-02-23 | ||
| 507 | 2017-09-01 | ||||
| 507 | 2016-09-01 |
| 2019: SHORT-TERM DISABILITY 2019 form 5500 responses | ||
|---|---|---|
| 2019-09-01 | Type of plan entity | Single employer plan |
| 2019-09-01 | Submission has been amended | Yes |
| 2019-09-01 | Plan funding arrangement – Insurance | Yes |
| 2019-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: SHORT-TERM DISABILITY 2017 form 5500 responses | ||
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: SHORT-TERM DISABILITY 2016 form 5500 responses | ||
| 2016-09-01 | Type of plan entity | Single employer plan |
| 2016-09-01 | First time form 5500 has been submitted | Yes |
| 2016-09-01 | Plan funding arrangement – Insurance | Yes |
| 2016-09-01 | Plan benefit arrangement – Insurance | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |
| Policy contract number | 552721 |
| Policy instance | 1 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) | |
| Policy contract number | 160225 |
| Policy instance | 1 |
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