401k Plan data: HILLSDALE FURNITURE HEALTH AND WELFARE PLAN plan

HILLSDALE FURNITURE HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	HILLSDALE FURNITURE HEALTH AND WELFARE PLAN
Plan identification number	501

HILLSDALE FURNITURE 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) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

HILLSDALE FURNITURE LLC has sponsored the creation of one or more 401k plans.

Company Name: HILLSDALE FURNITURE LLC

Employer identification number (EIN): 200235285

NAIC Classification: 423200

Additional information about HILLSDALE FURNITURE LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 3704880

More information about HILLSDALE FURNITURE LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HILLSDALE FURNITURE HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-06-01 DOUG HANBY 2023-10-18
501 2021-06-01 NICK CEASE 2022-11-03
501 2020-06-01 CHRISTINE LOVE 2021-10-21

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-06-01	DOUG HANBY	2023-10-18
501	2021-06-01	NICK CEASE	2022-11-03
501	2020-06-01	CHRISTINE LOVE	2021-10-21

Plan Statistics for HILLSDALE FURNITURE HEALTH AND WELFARE PLAN

401k plan membership statisitcs for HILLSDALE FURNITURE HEALTH AND WELFARE PLAN

Measure Date Value
2022: HILLSDALE FURNITURE HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-06-01 145
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 143
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 2022-06-01 143
Number of employers contributing to the scheme 2022-06-01 0
2021: HILLSDALE FURNITURE HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-06-01 138
Total number of active participants reported on line 7a of the Form 5500 2021-06-01 145
Number of retired or separated participants receiving benefits 2021-06-01 0
Number of other retired or separated participants entitled to future benefits 2021-06-01 0
Total of all active and inactive participants 2021-06-01 145
Number of employers contributing to the scheme 2021-06-01 0
2020: HILLSDALE FURNITURE HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-06-01 100
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 138
Number of retired or separated participants receiving benefits 2020-06-01 0
Number of other retired or separated participants entitled to future benefits 2020-06-01 0
Total of all active and inactive participants 2020-06-01 138
Number of employers contributing to the scheme 2020-06-01 0

Measure	Date	Value
2022: HILLSDALE FURNITURE HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-06-01	145
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	143
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	143
Number of employers contributing to the scheme	2022-06-01	0
2021: HILLSDALE FURNITURE HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-06-01	138
Total number of active participants reported on line 7a of the Form 5500	2021-06-01	145
Number of retired or separated participants receiving benefits	2021-06-01	0
Number of other retired or separated participants entitled to future benefits	2021-06-01	0
Total of all active and inactive participants	2021-06-01	145
Number of employers contributing to the scheme	2021-06-01	0
2020: HILLSDALE FURNITURE HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-06-01	100
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	138
Number of retired or separated participants receiving benefits	2020-06-01	0
Number of other retired or separated participants entitled to future benefits	2020-06-01	0
Total of all active and inactive participants	2020-06-01	138
Number of employers contributing to the scheme	2020-06-01	0

Form 5500 Responses for HILLSDALE FURNITURE HEALTH AND WELFARE PLAN

2022: HILLSDALE FURNITURE HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2021: HILLSDALE FURNITURE HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-06-01	Type of plan entity	Single employer plan
2021-06-01	Plan funding arrangement – Insurance	Yes
2021-06-01	Plan benefit arrangement – Insurance	Yes
2020: HILLSDALE FURNITURE HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	First time form 5500 has been submitted	Yes
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

838884

Policy instance

Insurance contract or identification number	838884
Number of Individuals Covered	89
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $7,374
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 $74,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,374
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPR0AFXF

Policy instance

Insurance contract or identification number	GUPR0AFXF
Number of Individuals Covered	41
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $2,879
Total amount of fees paid to insurance company	USD $1,639
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,879
Amount paid for insurance broker fees	1639
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

891199G

Policy instance

Insurance contract or identification number	891199G
Number of Individuals Covered	143
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $7,094
Total amount of fees paid to insurance company	USD $4,216
Life Insurance Welfare Benefit	Yes
Temporary Disability 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 $40,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,556
Amount paid for insurance broker fees	936
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

838884

Policy instance

Insurance contract or identification number	838884
Number of Individuals Covered	87
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $29,058
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $974,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,058
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

838884

Policy instance

Insurance contract or identification number	838884
Number of Individuals Covered	83
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $6,477
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 $64,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,477
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPR0AFXF

Policy instance

Insurance contract or identification number	GUPR0AFXF
Number of Individuals Covered	45
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $2,864
Total amount of fees paid to insurance company	USD $1,297
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,864
Amount paid for insurance broker fees	1297
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

891199G

Policy instance

Insurance contract or identification number	891199G
Number of Individuals Covered	145
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $6,078
Total amount of fees paid to insurance company	USD $1,345
Life Insurance Welfare Benefit	Yes
Temporary Disability 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 $40,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,078
Amount paid for insurance broker fees	1345
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

838884

Policy instance

Insurance contract or identification number	838884
Number of Individuals Covered	90
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $29,133
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $972,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,133
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

838884

Policy instance

Insurance contract or identification number	838884
Number of Individuals Covered	88
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $6,163
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 $61,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,163
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUPR0AFXF

Policy instance

Insurance contract or identification number	GUPR0AFXF
Number of Individuals Covered	44
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $2,279
Total amount of fees paid to insurance company	USD $1,476
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,279
Amount paid for insurance broker fees	1476
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

891199G

Policy instance

Insurance contract or identification number	891199G
Number of Individuals Covered	138
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $6,386
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability 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 $42,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,386
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

838884

Policy instance

Insurance contract or identification number	838884
Number of Individuals Covered	92
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $28,551
Total amount of fees paid to insurance company	USD $500
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $951,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,551
Amount paid for insurance broker fees	500
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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Company Name:	HILLSDALE FURNITURE LLC
Employer identification number (EIN):	200235285
NAIC Classification:	423200

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	3704880