401k Plan data: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN plan

PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 401k Plan overview

Plan Name	PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN
Plan identification number	502

PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

PANDROL USA, LP has sponsored the creation of one or more 401k plans.

Company Name: PANDROL USA, LP

Employer identification number (EIN): 223554003

NAIC Classification: 332900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2016-01-01 RIA GAINES
502 2015-01-01 RIA GAINESE
502 2014-01-01 MARILYN D. MACFARLANE MARILYN D. MACFARLANE 2015-10-15
502 2013-01-01 MARILYN D. MACFARLANE MARILYN D. MACFARLANE 2015-10-15

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
502	2016-01-01	RIA GAINES
502	2015-01-01	RIA GAINESE
502	2014-01-01	MARILYN D. MACFARLANE	MARILYN D. MACFARLANE	2015-10-15
502	2013-01-01	MARILYN D. MACFARLANE	MARILYN D. MACFARLANE	2015-10-15

Plan Statistics for PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN

401k plan membership statisitcs for PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN

Measure Date Value
2016: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 126
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
2015: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 111
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 126
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 126
2014: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 106
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 111
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 111
2013: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 102
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 106
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 106

Measure	Date	Value
2016: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	126
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
2015: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	111
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	126
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	126
2014: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	106
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	111
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	111
2013: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	102
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	106
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	106

Form 5500 Responses for PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN

2016: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	Yes
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: PANDROL USA MEDICAL, LIFE, AD&D AND LTD PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	First time form 5500 has been submitted	Yes
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

847336

Policy instance

Insurance contract or identification number	847336
Number of Individuals Covered	126
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,670
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
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 $71,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,666
Insurance broker organization code?	3
Insurance broker name	HAY HUGGINS PLAN SERVICES, INC.

HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )

Policy contract number

8002F

Policy instance

Insurance contract or identification number	8002F
Number of Individuals Covered	117
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $79,695
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
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
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 $1,648,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $79,695
Insurance broker organization code?	3
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0847336

Policy instance

Insurance contract or identification number	0847336
Number of Individuals Covered	227
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $61,520
Total amount of fees paid to insurance company	USD $39
Are there contracts with allocated funds for individual policies?	No
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	Yes
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $1,566,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,064
Insurance broker organization code?	3
Amount paid for insurance broker fees	39
Additional information about fees paid to insurance broker	INDIRECT COMPENSATION
Insurance broker name	CORPORATE SYNERGIES GROUP LLC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0847336

Policy instance

Insurance contract or identification number	0847336
Number of Individuals Covered	106
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,845
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $166,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,845
Insurance broker organization code?	3
Insurance broker name	HAY HUGGINS PLAN SERVICES, INC.

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95287 )

Policy contract number

0847336HNO

Policy instance

Insurance contract or identification number	0847336HNO
Number of Individuals Covered	174
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $46,938
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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
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 $1,134,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,938
Insurance broker organization code?	3
Insurance broker name	HAY HUGGINS PLAN SERVICES INC

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Company Name:	PANDROL USA, LP
Employer identification number (EIN):	223554003
NAIC Classification:	332900