401k Plan data: MICHIGAN CARPET DELIVERY BENEFIT PLAN plan

MICHIGAN CARPET DELIVERY BENEFIT PLAN 401k Plan overview

Plan Name	MICHIGAN CARPET DELIVERY BENEFIT PLAN
Plan identification number	501

MICHIGAN CARPET DELIVERY BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

SSBB INC has sponsored the creation of one or more 401k plans.

Company Name: SSBB INC

Employer identification number (EIN): 270051057

NAIC Classification: 238300

Additional information about SSBB INC

Jurisdiction of Incorporation: Georgia Department of States Corporations Division

Incorporation Date:

Company Identification Number: 1559279

More information about SSBB INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MICHIGAN CARPET DELIVERY BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-06-01 RICHARD WALDNER 2021-10-19
501 2019-06-01 RICHARD WALDNER 2020-12-15

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2020-06-01	RICHARD WALDNER	2021-10-19
501	2019-06-01	RICHARD WALDNER	2020-12-15

Plan Statistics for MICHIGAN CARPET DELIVERY BENEFIT PLAN

401k plan membership statisitcs for MICHIGAN CARPET DELIVERY BENEFIT PLAN

Measure Date Value
2020: MICHIGAN CARPET DELIVERY BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-06-01 102
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 78
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 78
Number of employers contributing to the scheme 2020-06-01 0
2019: MICHIGAN CARPET DELIVERY BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-06-01 103
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 102
Number of retired or separated participants receiving benefits 2019-06-01 0
Number of other retired or separated participants entitled to future benefits 2019-06-01 0
Total of all active and inactive participants 2019-06-01 102
Number of employers contributing to the scheme 2019-06-01 0

Measure	Date	Value
2020: MICHIGAN CARPET DELIVERY BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-06-01	102
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	78
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	78
Number of employers contributing to the scheme	2020-06-01	0
2019: MICHIGAN CARPET DELIVERY BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-06-01	103
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	102
Number of retired or separated participants receiving benefits	2019-06-01	0
Number of other retired or separated participants entitled to future benefits	2019-06-01	0
Total of all active and inactive participants	2019-06-01	102
Number of employers contributing to the scheme	2019-06-01	0

Form 5500 Responses for MICHIGAN CARPET DELIVERY BENEFIT PLAN

2020: MICHIGAN CARPET DELIVERY BENEFIT PLAN 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes
2019: MICHIGAN CARPET DELIVERY BENEFIT PLAN 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	First time form 5500 has been submitted	Yes
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

281129

Policy instance

Insurance contract or identification number	281129
Number of Individuals Covered	47
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $12,958
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?	No
Commission paid to Insurance Broker	USD $12,958
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

281129

Policy instance

Insurance contract or identification number	281129
Number of Individuals Covered	97
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $32,051
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?	No
Commission paid to Insurance Broker	USD $32,051
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10173201001

Policy instance

Insurance contract or identification number	10173201001
Number of Individuals Covered	160
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $1,339
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,422
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,339
Insurance broker organization code?	3

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

7684

Policy instance

Insurance contract or identification number	7684
Number of Individuals Covered	183
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $4,570
Total amount of fees paid to insurance company	USD $153
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,134
Amount paid for insurance broker fees	153
Additional information about fees paid to insurance broker	RETENTION BONUS
Insurance broker organization code?	3

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

281129

Policy instance

Insurance contract or identification number	281129
Number of Individuals Covered	47
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $8,910
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?	No
Commission paid to Insurance Broker	USD $8,910
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

281129

Policy instance

Insurance contract or identification number	281129
Number of Individuals Covered	99
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $18,465
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?	No
Commission paid to Insurance Broker	USD $18,465
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10173201001

Policy instance

Insurance contract or identification number	10173201001
Number of Individuals Covered	155
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $1,426
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,426
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

7684

Policy instance

Insurance contract or identification number	7684
Number of Individuals Covered	162
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $4,711
Total amount of fees paid to insurance company	USD $226
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,159
Amount paid for insurance broker fees	105
Additional information about fees paid to insurance broker	NEW BUSINESS BONUS RETENTION BONUS
Insurance broker organization code?	3

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Company Name:	SSBB INC
Employer identification number (EIN):	270051057
NAIC Classification:	238300

Jurisdiction of Incorporation:	Georgia Department of States Corporations Division
Incorporation Date:
Company Identification Number:	1559279