401k Plan data: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN plan

MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 401k Plan overview

Plan Name	MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN
Plan identification number	504

MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

MIDSTATES PETROLEUM COMPANY has sponsored the creation of one or more 401k plans.

Company Name: MIDSTATES PETROLEUM COMPANY

Employer identification number (EIN): 263162434

NAIC Classification: 211120
NAIC Description: Crude Petroleum Extraction

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
504 2017-09-01
504 2016-09-01 KIM HARDING KIM HARDING 2018-03-26
504 2015-09-01 KIM HARDING KIM HARDING 2017-04-12
504 2014-09-01 KIM HARDING
504 2013-09-01 KELLY WALKER

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
504	2017-09-01
504	2016-09-01	KIM HARDING	KIM HARDING	2018-03-26
504	2015-09-01	KIM HARDING	KIM HARDING	2017-04-12
504	2014-09-01	KIM HARDING
504	2013-09-01	KELLY WALKER

Plan Statistics for MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN

401k plan membership statisitcs for MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN

Measure Date Value
2017: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2017 401k membership
Total participants, beginning-of-year 2017-09-01 123
Total number of active participants reported on line 7a of the Form 5500 2017-09-01 0
Number of retired or separated participants receiving benefits 2017-09-01 0
Number of other retired or separated participants entitled to future benefits 2017-09-01 0
Total of all active and inactive participants 2017-09-01 0
2016: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2016 401k membership
Total participants, beginning-of-year 2016-09-01 119
Total number of active participants reported on line 7a of the Form 5500 2016-09-01 123
Number of retired or separated participants receiving benefits 2016-09-01 0
Number of other retired or separated participants entitled to future benefits 2016-09-01 0
Total of all active and inactive participants 2016-09-01 123
2015: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2015 401k membership
Total participants, beginning-of-year 2015-09-01 157
Total number of active participants reported on line 7a of the Form 5500 2015-09-01 118
Number of retired or separated participants receiving benefits 2015-09-01 0
Number of other retired or separated participants entitled to future benefits 2015-09-01 0
Total of all active and inactive participants 2015-09-01 118
2014: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2014 401k membership
Total participants, beginning-of-year 2014-09-01 192
Total number of active participants reported on line 7a of the Form 5500 2014-09-01 158
Total of all active and inactive participants 2014-09-01 158
Total participants 2014-09-01 158
2013: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2013 401k membership
Total participants, beginning-of-year 2013-09-01 155
Total number of active participants reported on line 7a of the Form 5500 2013-09-01 197
Number of retired or separated participants receiving benefits 2013-09-01 0
Number of other retired or separated participants entitled to future benefits 2013-09-01 0
Total of all active and inactive participants 2013-09-01 197
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-09-01 0
Total participants 2013-09-01 197

Measure	Date	Value
2017: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2017 401k membership
Total participants, beginning-of-year	2017-09-01	123
Total number of active participants reported on line 7a of the Form 5500	2017-09-01	0
Number of retired or separated participants receiving benefits	2017-09-01	0
Number of other retired or separated participants entitled to future benefits	2017-09-01	0
Total of all active and inactive participants	2017-09-01	0
2016: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2016 401k membership
Total participants, beginning-of-year	2016-09-01	119
Total number of active participants reported on line 7a of the Form 5500	2016-09-01	123
Number of retired or separated participants receiving benefits	2016-09-01	0
Number of other retired or separated participants entitled to future benefits	2016-09-01	0
Total of all active and inactive participants	2016-09-01	123
2015: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2015 401k membership
Total participants, beginning-of-year	2015-09-01	157
Total number of active participants reported on line 7a of the Form 5500	2015-09-01	118
Number of retired or separated participants receiving benefits	2015-09-01	0
Number of other retired or separated participants entitled to future benefits	2015-09-01	0
Total of all active and inactive participants	2015-09-01	118
2014: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2014 401k membership
Total participants, beginning-of-year	2014-09-01	192
Total number of active participants reported on line 7a of the Form 5500	2014-09-01	158
Total of all active and inactive participants	2014-09-01	158
Total participants	2014-09-01	158
2013: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2013 401k membership
Total participants, beginning-of-year	2013-09-01	155
Total number of active participants reported on line 7a of the Form 5500	2013-09-01	197
Number of retired or separated participants receiving benefits	2013-09-01	0
Number of other retired or separated participants entitled to future benefits	2013-09-01	0
Total of all active and inactive participants	2013-09-01	197
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-09-01	0
Total participants	2013-09-01	197

Form 5500 Responses for MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN

2017: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2017 form 5500 responses
2017-09-01	Type of plan entity	Single employer plan
2017-09-01	This submission is the final filing	Yes
2017-09-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2017-09-01	Plan funding arrangement – Insurance	Yes
2017-09-01	Plan benefit arrangement – Insurance	Yes
2016: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2016 form 5500 responses
2016-09-01	Type of plan entity	Single employer plan
2016-09-01	Submission has been amended	No
2016-09-01	This submission is the final filing	No
2016-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-09-01	Plan is a collectively bargained plan	No
2016-09-01	Plan funding arrangement – Insurance	Yes
2016-09-01	Plan benefit arrangement – Insurance	Yes
2015: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2015 form 5500 responses
2015-09-01	Type of plan entity	Single employer plan
2015-09-01	Submission has been amended	No
2015-09-01	This submission is the final filing	No
2015-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-09-01	Plan is a collectively bargained plan	No
2015-09-01	Plan funding arrangement – Insurance	Yes
2015-09-01	Plan benefit arrangement – Insurance	Yes
2014: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2014 form 5500 responses
2014-09-01	Type of plan entity	Single employer plan
2014-09-01	Submission has been amended	No
2014-09-01	This submission is the final filing	No
2014-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-09-01	Plan is a collectively bargained plan	No
2014-09-01	Plan funding arrangement – Insurance	Yes
2014-09-01	Plan benefit arrangement – Insurance	Yes
2013: MIDSTATES PETROLEUM COMPANY BASIC AD&D PLAN 2013 form 5500 responses
2013-09-01	Type of plan entity	Single employer plan
2013-09-01	First time form 5500 has been submitted	Yes
2013-09-01	Submission has been amended	No
2013-09-01	This submission is the final filing	No
2013-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-09-01	Plan is a collectively bargained plan	No
2013-09-01	Plan funding arrangement – Insurance	Yes
2013-09-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GL156463

Policy instance

Insurance contract or identification number	GL156463
Number of Individuals Covered	131
Insurance policy start date	2017-09-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $396
Total amount of fees paid to insurance company	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $1,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $396
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10206916

Policy instance

Insurance contract or identification number	10206916
Number of Individuals Covered	120
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $7,783
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	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 $51,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,440
Insurance broker organization code?	3
Insurance broker name	GALLAGEHER BENEFIT SERVICES, INC.

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

Policy contract number

303734

Policy instance

Insurance contract or identification number	303734
Number of Individuals Covered	158
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $515
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	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 $7,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $515
Insurance broker organization code?	3
Insurance broker name	CURTIS MOSLEY

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

Policy contract number

303734

Policy instance

Insurance contract or identification number	303734
Number of Individuals Covered	197
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $378
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	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 $9,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $378
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	CURTIS CLARKE MOSLEY

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Company Name:	MIDSTATES PETROLEUM COMPANY
Employer identification number (EIN):	263162434
NAIC Classification:	211120
NAIC Description:	Crude Petroleum Extraction