401k Plan data: BAYSTATE POOL SUPPLIES, INC. BENEFIT PLAN plan

BAYSTATE POOL SUPPLIES, INC. BENEFIT PLAN 401k Plan overview

Plan Name	BAYSTATE POOL SUPPLIES, INC. BENEFIT PLAN
Plan identification number	501

BAYSTATE POOL SUPPLIES, INC. BENEFIT 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

BAYSTATE POOL SUPPLIES, INC. has sponsored the creation of one or more 401k plans.

Company Name: BAYSTATE POOL SUPPLIES, INC.

Employer identification number (EIN): 043098928

NAIC Classification: 423400

Additional information about BAYSTATE POOL SUPPLIES, INC.

Jurisdiction of Incorporation: Florida Department of State Division of Corporations

Incorporation Date: 2014-01-24

Company Identification Number: P14000007741

Legal Registered Office Address: 1200 South Pine Island Road

Plantation

33324

More information about BAYSTATE POOL SUPPLIES, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BAYSTATE POOL SUPPLIES, INC. BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-06-01 ELAINE TILLY 2023-12-18

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-06-01	ELAINE TILLY	2023-12-18

Plan Statistics for BAYSTATE POOL SUPPLIES, INC. BENEFIT PLAN

401k plan membership statisitcs for BAYSTATE POOL SUPPLIES, INC. BENEFIT PLAN

Measure Date Value
2022: BAYSTATE POOL SUPPLIES, INC. BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-06-01 100
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 284
Number of retired or separated participants receiving benefits 2022-06-01 0
Number of other retired or separated participants entitled to future benefits 2022-06-01 0
Total of all active and inactive participants 2022-06-01 284
Number of employers contributing to the scheme 2022-06-01 0

Measure	Date	Value
2022: BAYSTATE POOL SUPPLIES, INC. BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-06-01	100
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	284
Number of retired or separated participants receiving benefits	2022-06-01	0
Number of other retired or separated participants entitled to future benefits	2022-06-01	0
Total of all active and inactive participants	2022-06-01	284
Number of employers contributing to the scheme	2022-06-01	0

Form 5500 Responses for BAYSTATE POOL SUPPLIES, INC. BENEFIT PLAN

2022: BAYSTATE POOL SUPPLIES, INC. BENEFIT PLAN 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	First time form 5500 has been submitted	Yes
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4960391

Policy instance

Insurance contract or identification number	4960391
Number of Individuals Covered	244
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $67,245
Total amount of fees paid to insurance company	USD $32,888
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $67,245
Amount paid for insurance broker fees	32888
Additional information about fees paid to insurance broker	OTHER COMMISSION, NON-MONETARY COMENSATION
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

953059

Policy instance

Insurance contract or identification number	953059
Number of Individuals Covered	194
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $4,834
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,834
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

897573G

Policy instance

Insurance contract or identification number	897573G
Number of Individuals Covered	284
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $2,037
Total amount of fees paid to insurance company	USD $1,426
Life 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 $20,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,037
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E5813142

Policy instance

Insurance contract or identification number	E5813142
Number of Individuals Covered	166
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $68,816
Total amount of fees paid to insurance company	USD $34,411
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $119,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,758
Amount paid for insurance broker fees	23168
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

Potentially related plans

BAYSTATE POOL SUPPLIES 401K PLAN [EIN = 042445529]

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Company Name:	BAYSTATE POOL SUPPLIES, INC.
Employer identification number (EIN):	043098928
NAIC Classification:	423400

Jurisdiction of Incorporation:	Florida Department of State Division of Corporations
Incorporation Date:	2014-01-24
Company Identification Number:	P14000007741
Legal Registered Office Address:	1200 South Pine Island Road Plantation 33324