401k Plan data: SPECIALIZED BICYCLE COMPONENTS HEALTH AND WELFARE PLAN plan

SPECIALIZED BICYCLE COMPONENTS HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	SPECIALIZED BICYCLE COMPONENTS HEALTH AND WELFARE PLAN
Plan identification number	505

SPECIALIZED BICYCLE COMPONENTS 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) Prepaid legal Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

SPECIALIZED BICYCLE COMPONENTS has sponsored the creation of one or more 401k plans.

Company Name: SPECIALIZED BICYCLE COMPONENTS

Employer identification number (EIN): 881246434

NAIC Classification: 423910
NAIC Description: Sporting and Recreational Goods and Supplies Merchant Wholesalers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SPECIALIZED BICYCLE COMPONENTS HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2022-01-01 IRENE PAPADIMITRATOS 2023-09-29

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
505	2022-01-01	IRENE PAPADIMITRATOS	2023-09-29

Plan Statistics for SPECIALIZED BICYCLE COMPONENTS HEALTH AND WELFARE PLAN

401k plan membership statisitcs for SPECIALIZED BICYCLE COMPONENTS HEALTH AND WELFARE PLAN

Measure Date Value
2022: SPECIALIZED BICYCLE COMPONENTS HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 755
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 827
Number of retired or separated participants receiving benefits 2022-01-01 2
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 829
Number of employers contributing to the scheme 2022-01-01 0

Measure	Date	Value
2022: SPECIALIZED BICYCLE COMPONENTS HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	755
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	827
Number of retired or separated participants receiving benefits	2022-01-01	2
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	829
Number of employers contributing to the scheme	2022-01-01	0

Form 5500 Responses for SPECIALIZED BICYCLE COMPONENTS HEALTH AND WELFARE PLAN

2022: SPECIALIZED BICYCLE COMPONENTS HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

6090260

Policy instance

Insurance contract or identification number	6090260
Number of Individuals Covered	68
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,634
Total amount of fees paid to insurance company	USD $296
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $17,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,634
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605020

Policy instance

Insurance contract or identification number	605020
Number of Individuals Covered	174
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $70,216
Total amount of fees paid to insurance company	USD $1,092
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $978,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $70,216
Amount paid for insurance broker fees	1092
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

4670A

Policy instance

Insurance contract or identification number	4670A
Number of Individuals Covered	18
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $65,607
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $543,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $65,607
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

276864

Policy instance

Insurance contract or identification number	276864
Number of Individuals Covered	560
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $11,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

04670A

Policy instance

Insurance contract or identification number	04670A
Number of Individuals Covered	18
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,716
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $14,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,716
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

818852

Policy instance

Insurance contract or identification number	818852
Number of Individuals Covered	827
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $22,516
Total amount of fees paid to insurance company	USD $6,522
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
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
Welfare Benefit Premiums Paid to Carrier	USD $356,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,516
Amount paid for insurance broker fees	6522
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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Company Name:	SPECIALIZED BICYCLE COMPONENTS
Employer identification number (EIN):	881246434
NAIC Classification:	423910
NAIC Description:	Sporting and Recreational Goods and Supplies Merchant Wholesalers