401k Plan data: GREEN RIVER CAPITAL HEALTH AND WELFARE PLAN plan

GREEN RIVER CAPITAL HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	GREEN RIVER CAPITAL HEALTH AND WELFARE PLAN
Plan identification number	501

GREEN RIVER CAPITAL HEALTH AND WELFARE 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) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

GREEN RIVER CAPITAL, LLC has sponsored the creation of one or more 401k plans.

Company Name: GREEN RIVER CAPITAL, LLC

Employer identification number (EIN): 453933740

NAIC Classification: 531210
NAIC Description: Offices of Real Estate Agents and Brokers

Additional information about GREEN RIVER CAPITAL, LLC

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2018-01-17

Company Identification Number: 0802913977

Legal Registered Office Address: 550 E SWEDESFORD RD STE 350

WAYNE
United States of America (USA)
19087

More information about GREEN RIVER CAPITAL, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GREEN RIVER CAPITAL HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2012-01-01 LYNDA MALMBORG

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2012-01-01	LYNDA MALMBORG

Plan Statistics for GREEN RIVER CAPITAL HEALTH AND WELFARE PLAN

401k plan membership statisitcs for GREEN RIVER CAPITAL HEALTH AND WELFARE PLAN

Measure Date Value
2012: GREEN RIVER CAPITAL HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 170
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 0
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 0

Measure	Date	Value
2012: GREEN RIVER CAPITAL HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	170
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	0
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	0

Form 5500 Responses for GREEN RIVER CAPITAL HEALTH AND WELFARE PLAN

2012: GREEN RIVER CAPITAL HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Multi-employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	Yes
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-034868

Policy instance

Insurance contract or identification number	010-034868
Number of Individuals Covered	167
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,240
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	No
Vision Insurance Welfare Benefit	Yes
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 $12,396
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $999
Insurance broker organization code?	3
Insurance broker name	HAYS OF UTAH INSURANCE SERVICES

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KMO5713917

Policy instance

Insurance contract or identification number	KMO5713917
Number of Individuals Covered	479
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $11,993
Total amount of fees paid to insurance company	USD $1,770
Are there contracts with allocated funds for individual policies?	No
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	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
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 $153,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,023
Amount paid for insurance broker fees	26
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THE HAYS GROUP INC

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

Policy contract number

0729931

Policy instance

Insurance contract or identification number	0729931
Number of Individuals Covered	347
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $40,027
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 $1,217,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,367
Insurance broker organization code?	3
Insurance broker name	HAYS COMPANIES

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Company Name:	GREEN RIVER CAPITAL, LLC
Employer identification number (EIN):	453933740
NAIC Classification:	531210
NAIC Description:	Offices of Real Estate Agents and Brokers

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2018-01-17
Company Identification Number:	0802913977
Legal Registered Office Address:	550 E SWEDESFORD RD STE 350 WAYNE United States of America (USA) 19087