401k Plan data: CODE FOR AMERICA LABS, INC HEALTH AND WELFARE PLAN plan

CODE FOR AMERICA LABS, INC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	CODE FOR AMERICA LABS, INC HEALTH AND WELFARE PLAN
Plan identification number	501

CODE FOR AMERICA LABS, 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) Other welfare benefit cover

401k Sponsoring company profile

CODE FOR AMERICA LABS INC has sponsored the creation of one or more 401k plans.

Company Name: CODE FOR AMERICA LABS INC

Employer identification number (EIN): 271067272

NAIC Classification: 000000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CODE FOR AMERICA LABS, INC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01 MELANIE HERNANDEZ 2024-01-22

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-07-01	MELANIE HERNANDEZ	2024-01-22

Plan Statistics for CODE FOR AMERICA LABS, INC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for CODE FOR AMERICA LABS, INC HEALTH AND WELFARE PLAN

Measure Date Value
2022: CODE FOR AMERICA LABS, INC HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 169
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 209
Number of retired or separated participants receiving benefits 2022-07-01 2
Number of other retired or separated participants entitled to future benefits 2022-07-01 0
Total of all active and inactive participants 2022-07-01 211
Number of employers contributing to the scheme 2022-07-01 0

Measure	Date	Value
2022: CODE FOR AMERICA LABS, INC HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	169
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	209
Number of retired or separated participants receiving benefits	2022-07-01	2
Number of other retired or separated participants entitled to future benefits	2022-07-01	0
Total of all active and inactive participants	2022-07-01	211
Number of employers contributing to the scheme	2022-07-01	0

Form 5500 Responses for CODE FOR AMERICA LABS, INC HEALTH AND WELFARE PLAN

2022: CODE FOR AMERICA LABS, INC HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	First time form 5500 has been submitted	Yes
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

927978

Policy instance

Insurance contract or identification number	927978
Number of Individuals Covered	221
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $72,553
Total amount of fees paid to insurance company	USD $7,035
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,612,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,553
Amount paid for insurance broker fees	7035
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

120204

Policy instance

Insurance contract or identification number	120204
Number of Individuals Covered	329
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $8,160
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $181,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,160
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

36500

Policy instance

Insurance contract or identification number	36500
Number of Individuals Covered	208
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $9,414
Total amount of fees paid to insurance company	USD $1,159
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 $89,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,414
Amount paid for insurance broker fees	1159
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

40149047

Policy instance

Insurance contract or identification number	40149047
Number of Individuals Covered	194
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $1,133
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,133
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HOLMAN PROFESSIONAL COUNSELING CENTERS (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

7122

Policy instance

Insurance contract or identification number	7122
Number of Individuals Covered	179
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $316
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $6,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $316
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

607439

Policy instance

Insurance contract or identification number	607439
Number of Individuals Covered	53
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $25,375
Total amount of fees paid to insurance company	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $807,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,375
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	CODE FOR AMERICA LABS INC
Employer identification number (EIN):	271067272
NAIC Classification:	000000