401k Plan data: AMERICAN STATE BANK EMPLOYEE BENEFITS PLAN plan

AMERICAN STATE BANK EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	AMERICAN STATE BANK EMPLOYEE BENEFITS PLAN
Plan identification number	501

AMERICAN STATE BANK EMPLOYEE BENEFITS 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

AMERICAN STATE BANK has sponsored the creation of one or more 401k plans.

Company Name: AMERICAN STATE BANK

Employer identification number (EIN): 750118190

NAIC Classification: 522110
NAIC Description: Commercial Banking

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMERICAN STATE BANK EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-07-01 NEELY POWELL 2022-03-15

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2020-07-01	NEELY POWELL	2022-03-15

Plan Statistics for AMERICAN STATE BANK EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for AMERICAN STATE BANK EMPLOYEE BENEFITS PLAN

Measure Date Value
2020: AMERICAN STATE BANK EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 100
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 144
Number of retired or separated participants receiving benefits 2020-07-01 0
Number of other retired or separated participants entitled to future benefits 2020-07-01 0
Total of all active and inactive participants 2020-07-01 144
Number of employers contributing to the scheme 2020-07-01 0

Measure	Date	Value
2020: AMERICAN STATE BANK EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	100
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	144
Number of retired or separated participants receiving benefits	2020-07-01	0
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	144
Number of employers contributing to the scheme	2020-07-01	0

Form 5500 Responses for AMERICAN STATE BANK EMPLOYEE BENEFITS PLAN

2020: AMERICAN STATE BANK EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	First time form 5500 has been submitted	Yes
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

297913

Policy instance

Insurance contract or identification number	297913
Number of Individuals Covered	167
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $59,275
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $976,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $53,348
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

M1T90

Policy instance

Insurance contract or identification number	M1T90
Number of Individuals Covered	10
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $2,790
Total amount of fees paid to insurance company	USD $31
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $5,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,396
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

35436

Policy instance

Insurance contract or identification number	35436
Number of Individuals Covered	87
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,286
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,286
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

VF025693

Policy instance

Insurance contract or identification number	VF025693
Number of Individuals Covered	144
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $10,472
Total amount of fees paid to insurance company	USD $996
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $52,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,851
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

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Company Name:	AMERICAN STATE BANK
Employer identification number (EIN):	750118190
NAIC Classification:	522110
NAIC Description:	Commercial Banking