401k Plan data: MAURICES, INCORPORATED HEALTH AND WELFARE BENEFITS PLAN plan

MAURICES, INCORPORATED HEALTH AND WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	MAURICES, INCORPORATED HEALTH AND WELFARE BENEFITS PLAN
Plan identification number	501

MAURICES, INCORPORATED HEALTH AND WELFARE 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) Prepaid legal Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

MAURICES, INCORPORATED has sponsored the creation of one or more 401k plans.

Company Name: MAURICES, INCORPORATED

Employer identification number (EIN): 122940677

NAIC Classification: 448120
NAIC Description: Women's Clothing Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MAURICES, INCORPORATED HEALTH AND WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-05-06 BRIAN THUN 2020-07-14

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2019-05-06	BRIAN THUN	2020-07-14

Plan Statistics for MAURICES, INCORPORATED HEALTH AND WELFARE BENEFITS PLAN

401k plan membership statisitcs for MAURICES, INCORPORATED HEALTH AND WELFARE BENEFITS PLAN

Measure Date Value
2019: MAURICES, INCORPORATED HEALTH AND WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-05-06 1,774
Total number of active participants reported on line 7a of the Form 5500 2019-05-06 2,140
Number of retired or separated participants receiving benefits 2019-05-06 2
Number of other retired or separated participants entitled to future benefits 2019-05-06 0
Total of all active and inactive participants 2019-05-06 2,142

Measure	Date	Value
2019: MAURICES, INCORPORATED HEALTH AND WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-05-06	1,774
Total number of active participants reported on line 7a of the Form 5500	2019-05-06	2,140
Number of retired or separated participants receiving benefits	2019-05-06	2
Number of other retired or separated participants entitled to future benefits	2019-05-06	0
Total of all active and inactive participants	2019-05-06	2,142

Form 5500 Responses for MAURICES, INCORPORATED HEALTH AND WELFARE BENEFITS PLAN

2019: MAURICES, INCORPORATED HEALTH AND WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-05-06	Type of plan entity	Single employer plan
2019-05-06	First time form 5500 has been submitted	Yes
2019-05-06	Submission has been amended	No
2019-05-06	This submission is the final filing	No
2019-05-06	This return/report is a short plan year return/report (less than 12 months)	Yes
2019-05-06	Plan is a collectively bargained plan	No
2019-05-06	Plan funding arrangement – Insurance	Yes
2019-05-06	Plan funding arrangement – General assets of the sponsor	Yes
2019-05-06	Plan benefit arrangement – Insurance	Yes
2019-05-06	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

DELTA DENTAL OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55034 )

Policy contract number

983209

Policy instance

Insurance contract or identification number	983209
Number of Individuals Covered	2254
Insurance policy start date	2019-05-06
Insurance policy end date	2019-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $500,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10222341001

Policy instance

Insurance contract or identification number	10222341001
Number of Individuals Covered	2298
Insurance policy start date	2019-05-06
Insurance policy end date	2019-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $78,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10222351001

Policy instance

Insurance contract or identification number	10222351001
Number of Individuals Covered	9
Insurance policy start date	2019-05-06
Insurance policy end date	2019-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 160631

Policy instance

Insurance contract or identification number	GL 160631
Number of Individuals Covered	2613
Insurance policy start date	2019-05-06
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,082
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $84,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,082
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAR 208587

Policy instance

Insurance contract or identification number	VAR 208587
Number of Individuals Covered	621
Insurance policy start date	2019-05-06
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $749
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $749
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 130890

Policy instance

Insurance contract or identification number	LTD 130890
Number of Individuals Covered	1471
Insurance policy start date	2019-05-06
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,097
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $121,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,097
Insurance broker organization code?	3

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Company Name:	MAURICES, INCORPORATED
Employer identification number (EIN):	122940677
NAIC Classification:	448120
NAIC Description:	Women's Clothing Stores