401k Plan data: FAIRFIELD-MAXWELL HEALTH & WELFARE BENEFIT PLAN plan

FAIRFIELD-MAXWELL HEALTH & WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	FAIRFIELD-MAXWELL HEALTH & WELFARE BENEFIT PLAN
Plan identification number	501

FAIRFIELD-MAXWELL HEALTH & WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

FAIRFIELD-MAXWELL, LTD has sponsored the creation of one or more 401k plans.

Company Name: FAIRFIELD-MAXWELL, LTD

Employer identification number (EIN): 131878439

NAIC Classification: 541360
NAIC Description: Geophysical Surveying and Mapping Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FAIRFIELD-MAXWELL HEALTH & WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-01-01 KARITA HANNON 2021-07-29
501 2020-01-01 KARITA HANNON 2022-09-20

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2020-01-01	KARITA HANNON	2021-07-29
501	2020-01-01	KARITA HANNON	2022-09-20

Plan Statistics for FAIRFIELD-MAXWELL HEALTH & WELFARE BENEFIT PLAN

401k plan membership statisitcs for FAIRFIELD-MAXWELL HEALTH & WELFARE BENEFIT PLAN

Measure Date Value
2020: FAIRFIELD-MAXWELL HEALTH & WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 122
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 86
Number of retired or separated participants receiving benefits 2020-01-01 21
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 107
Number of employers contributing to the scheme 2020-01-01 0

Measure	Date	Value
2020: FAIRFIELD-MAXWELL HEALTH & WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	122
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	86
Number of retired or separated participants receiving benefits	2020-01-01	21
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	107
Number of employers contributing to the scheme	2020-01-01	0

Form 5500 Responses for FAIRFIELD-MAXWELL HEALTH & WELFARE BENEFIT PLAN

2020: FAIRFIELD-MAXWELL HEALTH & WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	Yes
2020-01-01	This submission is the final filing	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30314

Policy instance

Insurance contract or identification number	30314
Number of Individuals Covered	120
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

903224

Policy instance

Insurance contract or identification number	903224
Number of Individuals Covered	3
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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
Welfare Benefit Premiums Paid to Carrier	USD $48,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA389046605701

Policy instance

Insurance contract or identification number	SA389046605701
Number of Individuals Covered	26
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $11,430
Total amount of fees paid to insurance company	USD $-3,483
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $76,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,430
Amount paid for insurance broker fees	-3483
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

ADDS00041

Policy instance

Insurance contract or identification number	ADDS00041
Number of Individuals Covered	86
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $174
Total amount of fees paid to insurance company	USD $270
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	270
Additional information about fees paid to insurance broker	BONUS, FEES
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

R0253104

Policy instance

Insurance contract or identification number	R0253104
Number of Individuals Covered	2
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $3
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

922738

Policy instance

Insurance contract or identification number	922738
Number of Individuals Covered	334
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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 $174,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )

Policy contract number

663085

Policy instance

Insurance contract or identification number	663085
Number of Individuals Covered	16
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,826
Total amount of fees paid to insurance company	USD $98
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	ACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $9,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,826
Amount paid for insurance broker fees	98
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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Company Name:	FAIRFIELD-MAXWELL, LTD
Employer identification number (EIN):	131878439
NAIC Classification:	541360
NAIC Description:	Geophysical Surveying and Mapping Services