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| Plan Name | LONG TERM DISABILITY INSURANCE |
| Plan identification number | 503 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | RALEY'S ARIZONA LLC |
| Employer identification number (EIN): | 872167964 |
| NAIC Classification: | 445110 |
| NAIC Description: | Supermarkets and Other Grocery (except Convenience) Stores |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 503 | 2024-01-01 | TIFFANIE BURKHALTER | |||
| 503 | 2023-01-01 | ||||
| 503 | 2023-01-01 | TIFFANIE BURKHALTER | |||
| 503 | 2023-01-01 | TIFFANIE BURKHALTER | |||
| 503 | 2022-01-01 | ||||
| 503 | 2022-01-01 | ELVA VIVAS | |||
| 503 | 2021-01-01 | ||||
| 503 | 2021-01-01 | ELVA VIVAS |
| Measure | Date | Value |
|---|---|---|
| 2023: LONG TERM DISABILITY INSURANCE 2023 401k membership | ||
| Total participants, beginning-of-year | 2023-01-01 | 3,005 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-01-01 | 0 |
| Total of all active and inactive participants | 2023-01-01 | 0 |
| 2022: LONG TERM DISABILITY INSURANCE 2022 401k membership | ||
| Total participants, beginning-of-year | 2022-01-01 | 3,126 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 2,983 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 22 |
| Total of all active and inactive participants | 2022-01-01 | 3,005 |
| 2021: LONG TERM DISABILITY INSURANCE 2021 401k membership | ||
| Total participants, beginning-of-year | 2021-01-01 | 3,381 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 3,126 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 3,126 |
| 2023: LONG TERM DISABILITY INSURANCE 2023 form 5500 responses | ||
|---|---|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Submission has been amended | No |
| 2023-01-01 | This submission is the final filing | Yes |
| 2023-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2023-01-01 | Plan is a collectively bargained plan | No |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022: LONG TERM DISABILITY INSURANCE 2022 form 5500 responses | ||
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: LONG TERM DISABILITY INSURANCE 2021 form 5500 responses | ||
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | Yes |
| 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 benefit arrangement – Insurance | Yes |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 643438 | ||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||
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| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 643438 | ||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||
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| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 643438 | ||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||||||||||||||
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 643438 | ||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||
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