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| Plan Name | PIGGLY WIGGLY MIDWEST, LLC EMPLOYEE BENEFIT PLAN |
| Plan identification number | 510 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | PIGGLY WIGGLY MIDWEST, LLC |
| Employer identification number (EIN): | 450575370 |
| NAIC Classification: | 424400 |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 510 | 2021-01-01 | ||||
| 510 | 2021-01-01 | MIKE ISKEN |
| 2021: PIGGLY WIGGLY MIDWEST, LLC EMPLOYEE BENEFIT PLAN 2021 form 5500 responses | ||
|---|---|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | First time form 5500 has been submitted | Yes |
| 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 – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | OK969418 |
| Policy instance | 12 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | FLX967930 |
| Policy instance | 10 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | OK969418 |
| Policy instance | 9 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | LK965401 |
| Policy instance | 8 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | FLX967930 |
| Policy instance | 7 |
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) | |
| Policy contract number | LGS01663-21 |
| Policy instance | 6 |
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) | |
| Policy contract number | 0141400000 |
| Policy instance | 5 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | LK965401 |
| Policy instance | 4 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | FLX967930 |
| Policy instance | 3 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | OK969418 |
| Policy instance | 2 |
| SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 ) | |
| Policy contract number | 172801 |
| Policy instance | 1 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | LK965401 |
| Policy instance | 11 |
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