401k Plan data: SAMUEL, SON & CO.(USA) INC. HEALTH BENEFITS PLAN plan

SAMUEL, SON & CO.(USA) INC. HEALTH BENEFITS PLAN 401k Plan overview

Plan Name	SAMUEL, SON & CO.(USA) INC. HEALTH BENEFITS PLAN
Plan identification number	515

SAMUEL, SON & CO.(USA) INC. HEALTH BENEFITS PLAN Benefits

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

401k Sponsoring company profile

SAMUEL SON & CO (USA) INC. 401K has sponsored the creation of one or more 401k plans.

Company Name: SAMUEL SON & CO (USA) INC. 401K

Employer identification number (EIN): 061251791

NAIC Classification: 332900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SAMUEL, SON & CO.(USA) INC. HEALTH BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
515 2019-01-01
515 2019-01-01 JAMES FUDACZ 2021-09-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
515	2019-01-01
515	2019-01-01	JAMES FUDACZ	2021-09-13

Plan Statistics for SAMUEL, SON & CO.(USA) INC. HEALTH BENEFITS PLAN

401k plan membership statisitcs for SAMUEL, SON & CO.(USA) INC. HEALTH BENEFITS PLAN

Measure Date Value
2019: SAMUEL, SON & CO.(USA) INC. HEALTH BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,676
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 2,584
Total of all active and inactive participants 2019-01-01 2,584
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Number of employers contributing to the scheme 2019-01-01 0

Measure	Date	Value
2019: SAMUEL, SON & CO.(USA) INC. HEALTH BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,676
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	2,584
Total of all active and inactive participants	2019-01-01	2,584
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Number of employers contributing to the scheme	2019-01-01	0

Form 5500 Responses for SAMUEL, SON & CO.(USA) INC. HEALTH BENEFITS PLAN

2019: SAMUEL, SON & CO.(USA) INC. HEALTH BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	Yes
2019-01-01	This submission is the final filing	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00333339

Policy instance

Insurance contract or identification number	00333339
Number of Individuals Covered	696
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00477826

Policy instance

Insurance contract or identification number	00477826
Number of Individuals Covered	1065
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

NOVA HEALTHCARE ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 52524 )

Policy contract number

02N/03N

Policy instance

Insurance contract or identification number	02N/03N
Number of Individuals Covered	635
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )

Policy contract number

39994

Policy instance

Insurance contract or identification number	39994
Number of Individuals Covered	276
Insurance policy start date	2019-04-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

333339

Policy instance

Insurance contract or identification number	333339
Number of Individuals Covered	696
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

477826

Policy instance

Insurance contract or identification number	477826
Number of Individuals Covered	1065
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

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Company Name:	SAMUEL SON & CO (USA) INC. 401K
Employer identification number (EIN):	061251791
NAIC Classification:	332900