401k Plan data: XSOLLA USA INC HEALTH AND WELFARE PLAN plan

XSOLLA USA INC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	XSOLLA USA INC HEALTH AND WELFARE PLAN
Plan identification number	501

XSOLLA USA INC 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

XSOLLA USA, INC. has sponsored the creation of one or more 401k plans.

Company Name: XSOLLA USA, INC.

Employer identification number (EIN): 264391913

NAIC Classification: 561900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan XSOLLA USA INC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 SOPHIA LISAIUS 2024-10-15

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-01-01	SOPHIA LISAIUS	2024-10-15

Form 5500 Responses for XSOLLA USA INC HEALTH AND WELFARE PLAN

2023: XSOLLA USA INC HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	First time form 5500 has been submitted	Yes
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

343018

Policy instance

Insurance contract or identification number	343018
Number of Individuals Covered	123
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

47490

Policy instance

Insurance contract or identification number	47490
Number of Individuals Covered	123
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $20,489
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
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 $178,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

L10118

Policy instance

Insurance contract or identification number	L10118
Number of Individuals Covered	123
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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Company Name:	XSOLLA USA, INC.
Employer identification number (EIN):	264391913
NAIC Classification:	561900