401k Plan data: HEALTH & LIFE INSURANCE PLAN OF CARROLL COMPANIES, INC. plan

HEALTH & LIFE INSURANCE PLAN OF CARROLL COMPANIES, INC. 401k Plan overview

Plan Name	HEALTH & LIFE INSURANCE PLAN OF CARROLL COMPANIES, INC.
Plan identification number	502

HEALTH & LIFE INSURANCE PLAN OF CARROLL COMPANIES, INC. Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Vision

401k Sponsoring company profile

CARROLL COMPANIES, INC. has sponsored the creation of one or more 401k plans.

Company Name: CARROLL COMPANIES, INC.

Employer identification number (EIN): 561087247

NAIC Classification: 424990
NAIC Description: Other Miscellaneous Nondurable Goods Merchant Wholesalers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HEALTH & LIFE INSURANCE PLAN OF CARROLL COMPANIES, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2021-03-01 JO EVELYN MILLER 2022-09-29

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2021-03-01	JO EVELYN MILLER	2022-09-29

Plan Statistics for HEALTH & LIFE INSURANCE PLAN OF CARROLL COMPANIES, INC.

401k plan membership statisitcs for HEALTH & LIFE INSURANCE PLAN OF CARROLL COMPANIES, INC.

Measure Date Value
2021: HEALTH & LIFE INSURANCE PLAN OF CARROLL COMPANIES, INC. 2021 401k membership
Total participants, beginning-of-year 2021-03-01 64
Total number of active participants reported on line 7a of the Form 5500 2021-03-01 64
Total of all active and inactive participants 2021-03-01 64

Measure	Date	Value
2021: HEALTH & LIFE INSURANCE PLAN OF CARROLL COMPANIES, INC. 2021 401k membership
Total participants, beginning-of-year	2021-03-01	64
Total number of active participants reported on line 7a of the Form 5500	2021-03-01	64
Total of all active and inactive participants	2021-03-01	64

Form 5500 Responses for HEALTH & LIFE INSURANCE PLAN OF CARROLL COMPANIES, INC.

2021: HEALTH & LIFE INSURANCE PLAN OF CARROLL COMPANIES, INC. 2021 form 5500 responses
2021-03-01	Type of plan entity	Single employer plan
2021-03-01	Submission has been amended	No
2021-03-01	This submission is the final filing	No
2021-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-03-01	Plan is a collectively bargained plan	No
2021-03-01	Plan funding arrangement – Insurance	Yes
2021-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-03-01	Plan benefit arrangement – Insurance	Yes
2021-03-01	Plan benefit arrangement – General assets of the sponsor	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

00629227

Policy instance

Insurance contract or identification number	00629227
Number of Individuals Covered	64
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $23,707
Total amount of fees paid to insurance company	USD $0
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?	No
Health Insurance Welfare Benefit	Yes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,707
Insurance broker organization code?	3

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Company Name:	CARROLL COMPANIES, INC.
Employer identification number (EIN):	561087247
NAIC Classification:	424990
NAIC Description:	Other Miscellaneous Nondurable Goods Merchant Wholesalers